Are these arousals? Help needed for PS settings

[Wellhellothere]

I also want to ask: Have you been changing the settings on this machine? I can't pick up all the settings for night of Dec. 10 from the OSCAR screen shot. But the Oscar screen shot seems to indicate Min EPAP = 8.0, Min PS = 3.0, and Max PS = 3.2. And I can't really determine Max IPAP. The stuff from SleepHQ seems to indicate that the settings are different:

The short answer is yes: I am trying to find the right pressure settings that make me feel better, as opposed to only looking at the data.

On Dec. 10th I used the ASVauto mode with Epap min at 7,6 and epap max at 9 (i believe), with a PS range of 3-8cm, which gives the machine some space to move around change the pressure when needed.

Since I felt absolutely awful the next morning, I tried the ASV mode on my machine with a fixed Epap of 8 and a PS min and PS max of 4, just to test if a mimicking a BiPAP would be beneficial to my sleep. After shedding all that weight, I am trying to tackle the narrowing of my airways, and not it closing off completely.

These are the data to last night, and I have to add that I feel pretty sleep deprived and cold. Lowering the epap probably wasn't a good idea.

https://sleephq.com/public/418fb40e-d40 ... aa4a65e67c
https://imgur.com/a/7RY9HvI

I feel significantly worse than the day before, so I need some help tweaking my pressure settings. I am leaning towards imcreasing the Epap and using a somewhat lower PS max/Ipap max, as I feel just knackered.

Can you have another look and see if for instance a high Ipap actually close my airways?

Thanks!

[robysue1]

I also want to say that SleepHQ has one funky pressure curve for this machine. Maybe that's because I don't know what a zoomed in version of a Resmed ASV machine's pressure curve looks like.

I don't believe SleepHQ supports ASV machines - don't see them mentioned in the list.

To handle ASVs requires *proper* display of the mask pressure trace.

I kind of suspected that.

I do have one question, though: On the night the OP showed us the Oscar data, he had min PS = 3.0 and max PS = 3.2.

Am I correct in thinking that keeping PS in that tight of a range kind of defeats the purpose of an ASV?

[Pugsy]

I do have one question, though: On the night the OP showed us the Oscar data, he had min PS = 3.0 and max PS = 3.2.

Am I correct in thinking that keeping PS in that tight of a range kind of defeats the purpose of an ASV?

If a person is using ASV to deal with central apneas then restricting PS that much definitely is defeating the purpose of using the ASV.
Some time ago I asked Jason just how much PS is needed to breathe for us when a central happens and he told me ideally at least 10 cm PS....maybe 8 cm if someone got lucky.

Now if someone is using ASV for some other reason than forcing a breath due to a central...doesn't hurt a thing to limit the PS.
All depends on what the machine is being used for.

[robysue1]

I also want to ask: Have you been changing the settings on this machine? I can't pick up all the settings for night of Dec. 10 from the OSCAR screen shot. But the Oscar screen shot seems to indicate Min EPAP = 8.0, Min PS = 3.0, and Max PS = 3.2. And I can't really determine Max IPAP. The stuff from SleepHQ seems to indicate that the settings are different:

The short answer is yes: I am trying to find the right pressure settings that make me feel better, as opposed to only looking at the data.

The problem with making such radical, multiple changes almost every night is that it's very difficult to tease out whether any of the changes made an actual difference and whether the difference was positive or negative.

On Dec. 10th I used the ASVauto mode with Epap min at 7,6 and epap max at 9 (i believe), with a PS range of 3-8cm, which gives the machine some space to move around change the pressure when needed.

But you went from what looks like settings of Min EPAP = 8.0, Min PS = 3.0, and Max PS = 3.2 (on the night for which you posted the OSCAR data) to changing all of Min EPAP, Max IPAP, and a drastically different PS range. Any one of those changes might have left you feeling awful the next morning.

These are the data to last night, and I have to add that I feel pretty sleep deprived and cold. Lowering the epap probably wasn't a good idea.

Min EPAP needs to be high enough where you are breathing comfortably. While ASV machines allow an EPAP below 4cm, you might be much more comfortable increasing min EPAP to 4 or 5 cm.

I feel significantly worse than the day before, so I need some help tweaking my pressure settings. I am leaning towards imcreasing the Epap and using a somewhat lower PS max/Ipap max, as I feel just knackered.

The problem with changing the settings every single night is that your body never has time to acclimate itself to how the new settings feel

Here's what I would suggest:

1) Have you ever had settings that you felt were comfortable to sleep with? If so, can you remember what they were? If so, go back to those settings and try really hard to not tweak any further for at least 3 or 4 days. Don't worry about the AHI. If the sleep goes from "bad" to "horrible", it's ok to go back to the last setting that was marginally acceptable.

2) Change one setting at a time. That's the only way to figure out whether your current problems are being caused by too low of an min EPAP, to wide of a PS range or too high of max EPAP. Also, as long as you are running in ASV mode, the min IPAP and max IPAP settings are also things that may need to be tweaked. But the correct way to tweak all of things is not at all clear: Your apnea is well managed by the xPAP, but you are worried you are having too many arousals. Those arousals may or may not even be related to your xPAP therapy: Spontaneous arousals are not caused by sleep disordered breathing events.

Can you have another look and see if for instance a high Ipap actually close my airways?

Not sure what you are asking for. Are you asking me whether your breathing gets less stable when the IPAP is high? That's above my pay grade.

I will say this, however: ASV machines are designed to treat central sleep apnea, not just OSA. And the way an ASV prevents strings of CAs from happening is by quite drastically increasing the IPAP when the machine thinks your breathing pattern indicates you may be developing a CO2 overshoot/undershoot cycle: When your brain is not sending the signal to the diaphragm to "inhale now", the machine ramps up the IPAP in an effort to keep you properly ventilated and to try to trigger you to start breathing on your own.

I'll end with this: Although your leaks are certainly well under the Resmed definition of "large leak", there is some evidence that you may occasionally waking up just enough to fiddle with the mask to fix a pesky not very big leak.

[palerider]

I also want to say that SleepHQ has one funky pressure curve for this machine. Maybe that's because I don't know what a zoomed in version of a Resmed ASV machine's pressure curve looks like.

I don't believe SleepHQ supports ASV machines - don't see them mentioned in the list.

To handle ASVs requires *proper* display of the mask pressure trace.

I kind of suspected that.

I do have one question, though: On the night the OP showed us the Oscar data, he had min PS = 3.0 and max PS = 3.2.

Am I correct in thinking that keeping PS in that tight of a range kind of defeats the purpose of an ASV?

Yes, that completely defeats the ASVs ability to do what ASVs were designed to do, provide that very high PS needed to adequately ventilate someone that's not trying to breathe, and hopefully normalize their breathing.

[palerider]

While ASV machines allow an EPAP below 4cm, you might be much more comfortable increasing min EPAP to 4 or 5 cm.

MinEPAP on a Resmed ASV is 4.

[Wellhellothere]

Hey you all,

To I have bought the ASV, not because I have centrals, but because it is bi-level and the pressure support range can be adapted towards the narrowing of my upper airways in the deeper sleep stages. I still feel sleep deprived and looking at last night's settings, I still notice difficulties breathing:

https://sleephq.com/public/2b0e8f8b-adb ... 25b50d1a43

I am using a full-face mask to prevent mouth leaks, but somehow I have the idea that nasal pillows (+ mouth taping), would be a more direct way to keep my upper airways open. From the 05:14:20 mark my flow rate is starting to show the flow rate becoming smaller, and at 05:17:20 you can notice the flow rate becoming dented. I take it this is flow limitation resulting in an arousal at 05:19:30. The pattern starts again around 05:29:20 and not long after I wake up. Similar obsstructed inspiration happens 02:40 onwards, and after 02:06:05, to give some examples.

So despite my data overall looking okay, when taking a closer look I do see the flow rate becoming "dented" and the machine increasing the PS, but NOT marking it as a FL. So even that in general it looks good, upon closer inspection there are signs that might explain me not feeling rested.

So currently I have gone back to the EPAP of 10 that did wasn't good, but also not horrible, with a higher and wider PS range of 4.4-6.4. Since I don't react too well to a big range of PS, my gut feeling says, stick to a fairly narrow PS range, but increase the PSmin and PSmax gradually by 0.2 or 0.4. In this case to 4.8 - 6.8.

Thanks your taking the time to review my data guys, I appreciate it.

Cheers, Erdinc

[robysue1]

Hey you all,

To I have bought the ASV, not because I have centrals, but because it is bi-level and the pressure support range can be adapted towards the narrowing of my upper airways in the deeper sleep stages. I still feel sleep deprived and looking at last night's settings, I still notice difficulties breathing:

https://sleephq.com/public/2b0e8f8b-adb ... 25b50d1a43

There is nothing in your data that screams "Fix this by tweaking the pressure settings!"

Quite frankly, I'm not seeing any significant evidence of "narrowing of your upper airway" either---the flow limitation curve is actually pretty minimal. Yes, there is some jaggedness in the flow rate if you zoom into where you are looking at maybe 30-60 seconds of data, but since almost all of the time there is no activity in the flow limitation graph, I'm more willing to believe these jaggedness may be caused by how SleepHQ is attempting to resample high-res data in order to make everything real time and quick. I can't prove that---not without having the actual data to analyze in Oscar on my own computer.

I don't doubt that you are feeling sleep deprived. But I do think you need to be considering explanations that may go beyond "sleep apnea" and "xPAP is not yet optimized."

It looks to me like you had no serious problem falling asleep on this night: Yes, there's a "false start" where you turn the machine off and back on, but regular sleep breathing seems to start within 10 minutes or so of you turning the machine on.

Then there is the restlessness between 5:20 and 6:00. It looks like during that 40 minute stretch you were not sound asleep: There is some stuff that looks like SWF, as well as two times when you turned the machine off and back on. It's possible that the leak at 5:28 is what woke you up.

I am using a full-face mask to prevent mouth leaks, but somehow I have the idea that nasal pillows (+ mouth taping), would be a more direct way to keep my upper airways open.

Why?

In all seriousness, the question you need to be asking yourself is this: Is using nasal pillows + mouth taping more or less comfortable than using a full-face mask?

There's not a right/wrong answer to that question: Some people are more comfortable with nasal pillows and taping. Others are more comfortable with the full face mask. But in either case, using something that allows you to sleep comfortably is critically important to addressing the on-going feeling that you are still not sleeping well with your machine.

From the 05:14:20 mark my flow rate is starting to show the flow rate becoming smaller, and at 05:17:20 you can notice the flow rate becoming dented. I take it this is flow limitation resulting in an arousal at 05:19:30. The pattern starts again around 05:29:20 and not long after I wake up.

Yes, there is a breathing change around 5:14. That could be as simple as changing from one sleep state to another. Yes, there is a small flow limitation around 5:17 or 5:18. Yes, there appears to be an arousal at 5:19:30, but its short. The bigger problem is that you wake up for real problem is that you wake up for real at 5:30 am and you turn the machine off for 5 minutes. A 5 minute wake is usually more significant (in terms of sleep quality) than a 30 second arousal.

It is possible that you were in a REM cycle before 5:14:20 and that you transitioned to a lighter stage of sleep followed by a typical "post-REM" wake at 5:30. The only problem that I see is that you didn't get immediately back to a sound sleep after turning the machine on at 5:36. But you turned the machine back off at 5:48. My guess is that you never fully transitioned back to sleep during the 12 minutes the xPAP was running between 5:36 and 5:48. And that's a long enough wake where it could negatively affect the quality of your sleep.

So despite my data overall looking okay, when taking a closer look I do see the flow rate becoming "dented" and the machine increasing the PS, but NOT marking it as a FL. So even that in general it looks good, upon closer inspection there are signs that might explain me not feeling rested.

Does it look just as "dented" in Oscar? Also, you need to understand why the ASV algorithm is increasing the pressure: The ASV algorithm is designed to treat central sleep apnea problems by massively increasing the PS in order to maintain breathing and to try to trigger a person to start breathing again during the part of the CO2 overshoot/undershoot cycle that leads to depressed respiration and central apneas. My understanding is it doesn't tend to score these things as "flow limitations" specifically because the ASV algorithm assumes the need to increase PS is caused by a central issue. In other words, while you are using your ASV as a bi-level machine, there are some differences in the algorithm. On a Resmed VAuto, both the EPAP and IPAP would be increased in the presence of flow limitations. And it could be that your ASV is not responding in an appropriate way specifically because it is an ASV, not a Vauto.

Similar obsstructed inspiration happens 02:40 onwards, and after 02:06:05, to give some examples

Yes, there are a few minor flow limitations in this time frame. The bits of breathing that you are worried might be arousals may just be related to changing sleep stages. I don't see anything here to be overly concerned about.

So currently I have gone back to the EPAP of 10 that did wasn't good, but also not horrible, with a higher and wider PS range of 4.4-6.4. Since I don't react too well to a big range of PS, my gut feeling says, stick to a fairly narrow PS range, but increase the PSmin and PSmax gradually by 0.2 or 0.4. In this case to 4.8 - 6.8.

I'm not sure I understand why you want to increase the PS, which is exactly what you will do if you increase PS min and PS max. In other words, I'm not sure why you think increasing the difference between EPAP and IPAP is going to smooth out your already reasonably uneventful flow limitation curve.

Personally, if I were you I would leave the settings alone for the next 4 or 5 days rather than starting to tweak them right now. Give your body a chance to figure out how the ASV algorithm works with your current settings. Give your body a chance to adjust to the machine doing what it's doing.

If you sleep is still "not good, but also not horrible" at the end of the 4 or 5 days, then you can change Min PS and Max PS by 0.2 or 0.4 cm and see what happens.

In the meantime, also consider the affect of non-apnea, non-xPAP things on your sleep. Get serious about sleep hygiene. If you consume a lot of caffeine, start limiting it by early afternoon. Make sure you don't drink any alcohol before bed.

[Wellhellothere]

Thanks a million for your response Roby Sue. I'll give the current settings a go for the upcoming days.

The lung doc should schedule in a titrationnight. Let's see if what that brings to light.

Since I hardly have a AHI worth mentioning, a static pressure support with some room for the EPR the AutoSV could be an option indeed. I will bring this up with her.

Again, thank you!