Smargie’s Therapy Thread...in Need of ASV Advice

[ajack]

Your doing great on your ASV

Thanks for the feedback and support, Jas.

when you are ready, you will see your doctor, you are still being lead down the garden path here.

I will be seeing my doctor on Monday. The appointment was set up as soon as I got my machine, and it was scheduled to be close to but after at least 30 days of treatment, per insurance requirements. I have no idea how she will feel about my having changed the prescribed setting the way I did, ajack, but if she takes the trouble to review my chart before seeing me, she'll remember that she completely dropped the ball last time, leaving me much worse off than when I came to her for help. I don't think she was surprised that I did my own research and sought advice elsewhere given how awful my numbers were. I'm not going to ignore what she says if she is unhappy about my current settings--I will tell her that making the settings so much higher without warning me that it would be such a drastic change, and one that I might not be able to tolerate, left me in a very difficult position. If it weren't for this forum I would have simply quit the ASV. Not being able to sleep and feeling ill with the pressures prescribed did me no good at all. I don't know why this is impossible for you to understand, and it seems like you are really looking forward to the possibility of my getting a good talking to. Instead of offering solutions (other than "just get used to it"), you've been nothing but the voice of doom and gloom and it has been the opposite of helpful.

You may have felt I haven't helped. I didn't give any pressure suggestions. I've told you to see the doctor to get checked out why you have aerophagia. I also suggested talking with your doctor on how an ASV works and why max PS is important. If she dropped the ball, you may need to see another doctor, at the end of the day you need a doctor that knows what they are doing. ASV is a specialist field. Your doctor isn't going to disagree with the manufacturer and sleep techs and will help you get the most out of your machine. It is understandable that you are seeing good AHI numbers and think that max ps is unimportant. I hope you looked at the ASV section of the sleep tech video, I put up for pugsy in my last post.

[palerider]

when you are ready, you will see your doctor, you are still being lead down the garden path here.

I don't know why this is impossible for you to understand, and it seems like you are really looking forward to the possibility of my getting a good talking to. Instead of offering solutions (other than "just get used to it"), you've been nothing but the voice of doom and gloom and it has been the opposite of helpful.

There's a really good reason that I recommend everyone put ajack on their foe list.

[Smargie]

Hi Smargie,

I found this site when I was ready to throw my own bilevel machine out the window. I made the suggested changes from forum members and I sleep so much better now. The reason I am chiming in, is that I too was anxious about my doctors visit. I thought for sure he would be mad. I went in to my doctors appointment, he said your numbers look great I will see you in a year. If he noticed I changed my settings he didn't say a word. I'm not even sure he noticed.

Thanks for chiming in. That really eases my mind...hopefully my doctor does the same. Unfortunately the appointment got canceled and now I'm not sure when I will be seeing her. This sleep clinic seems really disorganized! Do you have a thread detailing your journey? I would love to read about how you were stopped from throwing your machine out the window.

[babydinosnoreless]

Hi Smargie,

I found this site when I was ready to throw my own bilevel machine out the window. I made the suggested changes from forum members and I sleep so much better now. The reason I am chiming in, is that I too was anxious about my doctors visit. I thought for sure he would be mad. I went in to my doctors appointment, he said your numbers look great I will see you in a year. If he noticed I changed my settings he didn't say a word. I'm not even sure he noticed.

Thanks for chiming in. That really eases my mind...hopefully my doctor does the same. Unfortunately the appointment got canceled and now I'm not sure when I will be seeing her. This sleep clinic seems really disorganized! Do you have a thread detailing your journey? I would love to read about how you were stopped from throwing your machine out the window.

I do have a thread. Just reading back through some of it. Omg was I clueless. Everyone here was so nice and helpful. I still fight the leaks although i have changed masks and I can now sleep through them better.

viewtopic/t173584/baby-dinos-casa-de-lo ... e&start=60

[Smargie]

Question: Is it normal for EPAP to dip down to zero and stay there for a while? I thought it wouldn't/couldn't go below the set minimum of 4. I've been doing very well the past week -- many nights of 0s -- but the pressure is supposed to be continuous, isn't it? Or maybe I'm reading the chart wrong...

ASV Snip 2.PNG (140.94 KiB) Viewed 4009 times

Looks like 0 between 3:26 and 4:18 to me.

[Pugsy]

Which view are you looking at?
I don't see a drop below 0 on any of the pressure graphs.
Per the statistics...the EPAP minimum was 4.02

[idlewire]

That's just a data recording glitch. I've seen it happen on my ASV from time to time. You can see from the Mask Pressure chart that the EPAP did not actually drop at all.

[Jay Aitchsee]

It is odd that the reading at the cursor is 0.00. A glitch, no doubt.
However, it's the scale of the chart that prevents seeing the epap pressure at 4.0 from 3:26 until 4:18.
Right click in the label area at the left side of the pressure graph. In the drop down menu that will come up, select Y axis, then change the Scaling Mode from Auto to Override and enter something like 3.5 minimum and 15.0 Maximum and you will be able to see the continuous epap graphic.

[Smargie]

I changed the Y axis as Jay suggested and the green EPAP line still disappears completely. But it sounds like you're all confident that it's a glitch and nothing to worry about.

ASV Snip 3.PNG (150.74 KiB) Viewed 3961 times

[palerider]

I changed the Y axis as Jay suggested and the green EPAP line still disappears completely. But it sounds like you're all confident that it's a glitch and nothing to worry about.


ASV Snip 3.PNG

Look at the *actual* pressure (mask pressure)... where's the EPAP?

[Smargie]

Look at the *actual* pressure (mask pressure)... where's the EPAP?

Is that a rhetorical question? I'll answer if you really want me to because I'm scared to get on your bad side. Just kidding...thanks for your responses, everyone. You've convinced me that my machine is not broken and that I'm not so skilled at sleeping now that the EPAP can just take a break when it wants.

[Pugsy]

The pressure line sometimes show up wacko with empty spots. It's a software issue. If you want to use ResScan this won't happen.
A bug in the software.

If you look at the mask pressure line....no wacko empty spots.

[palerider]

Look at the *actual* pressure (mask pressure)... where's the EPAP?

Is that a rhetorical question? I'll answer if you really want me to because I'm scared to get on your bad side. Just kidding...thanks for your responses, everyone. You've convinced me that my machine is not broken and that I'm not so skilled at sleeping now that the EPAP can just take a break when it wants.

Just pointing out that the more important thing was what was showing as being recorded.. as opposed to the commanded pressure. Now, there will sometimes be times when the mask pressure shows glitches, usually when breathing really hard, and it shows lower pressure than it should.

But, yeah... glitches in the 'pressure' line.

[Smargie]

I'm still doing really well! I haven't made it to my follow up appointment with the doctor yet between her cancelling and then me, but I'm not too anxious about having changed the settings anymore. Pugsy, I wish I had followed your advice to just postpone treatment until seeing the doc the first time around back in March, when my charts were so ugly...I guess I've made some progress with my good girl complex as well.

I have a couple of questions. I haven't had a single (flagged) OA since starting the ASV. I guess that's not really a question...I'm just wondering if some people tend to have only hypopneas (and UAs or centrals in my case) when on ASV and why that would be.

How unusual is it to develop treatment related complex sleep apnea? I understand that if pressure is too high it can cause centrals, but what about this more permanent situation that happened with me?

When we first lowered my pressures to ease the aerophagia the plan was to raise them again slowly, as tolerated. Since my AHI has averaged .75 over the last 30 days, is there any reason to start titrating back up? The Rx was min EPAP 10, max IPAP 30, and PS 6 - 15. We eventually changed the settings to min EPAP 4, max IPAP 23, and PS 3 - 8. There is still a tolerable amount of aerophagia, so I'd rather not raise any of the settings unless there is a good reason to. My EPAP readings stay surprisingly low-- for example last night the med was 4.26, 95% was 5.16, and the max was 5.52, and that's pretty typical. IPAP averages for past 30 days are min 4.04, med 9.43, 95% 12.68, and max 17.68.

Is there a way to tell how much PS is being used and when? What is the difference between pressure support and back up? ASV vs. ASVAuto?

After reporting back what my doc says during my follow up appointment (unless it's anything radical), it seems like a good point to end my therapy thread and post further questions in new threads if and when they come up. Does this make sense?

Lastly, since you all have been sooooo helpful I'd like to contribute when I can. Obviously my knowledge is limited, but there are some easy questions I've chimed in on. I don't want to step on anyone's toes, though. Are there any general rules or am I free to use my own judgment?

[Pugsy]

How unusual is it to develop treatment related complex sleep apnea?

From what I have read...10 to 15 % of the people put on cpap will develop comp SA.
Also, it's not necessarily too high of a pressure...it can be any pressure. I have seen people get comp SA from 5 cm pressure.
While going to higher pressures might be a trigger for some people it really happens more with just any pressure than a high pressure.
It used to be that 10 cm was the cut off line and why a lot of the older auto machines wouldn't always go over 10 cm but that 10 cm rule has sort of been left by the wayside. Too many people have popped up with comp SA with pressures far under 10 cm.

Is there a way to tell how much PS is being used and when? What is the difference between pressure support and back up? ASV vs. ASVAuto?

You can see how much PS on the pressure graphs if you zoom way in.
Pressure support is simply the difference between EPAP (exhale) and IPAP (inhale).
Back up rate is just a number where the machine wants to make sure that you are taking a breath as often as you should be.
ASV mode...fixed EPAP but the PS will vary (auto adjust) as needed so IPAP varies.
ASVAuto mode....has a minimum and maximum EPAP setting...so EPAP can auto adjust along with PS...and end result IPAP variations.
It's EPAP that is doing the bulk of the job dealing with the obstructive side of things. Works the same way as apap machines...the pressure has to be high enough to hold the airway open.
PS is what deals with the centrals...rapid increase between inhale and exhale to jump start your breathing again when you don't breathe. Forces a breath and functions like a ventilator. That's why ASV machines are classified as non invasive ventilators...they force a breath but no tube is in the trachea (machines hooked up to a tube in the trachea are called invasive ventilators).

If you are having any aerophagia symptoms at all.....I wouldn't try to work up to the prescribed settings unless the doctor really wants it and can thoroughly explain why he might want it.

UA...unclassified apneas be it central or obstructive. ResMed doesn't do the FOT thing on the ASV machines so there is no way to tell the difference between an apnea that is obstructive vs open airway. We assume that since the machine deals with centrals that if anything is flagged in the UA basket that it is obstructive but that's something never really clearly stated in any documentation that I could ever find. If you don't ever see anything in the UA basket...that's good.

Hyponeas can be either obstructive or central in nature. The bulk are obstructive though. So if you are seeing a few hyponeas it just means that probably there's a flow reduction happening. All this is assuming you are actually asleep because you can still get false positive flagging just like we can get with the cpap/apap machines. I wouldn't worry about a few hyponeas even if for sure real asleep flagged. If there is a large number...maybe more EPAP or more PS to give you more IPAP.
Given your problems with aerophagia...I am really hesitant to start increasing that baseline all night EPAP pressures unless there is an urgent need. I think that the problems that come with the aerophagia will be worse than a handful of hyponeas now and then.
In your case if I was going to do anything at all...maybe increase PS max and let the machine sort it out. It won't go up unless it has a need.

Lastly, since you all have been sooooo helpful I'd like to contribute when I can. Obviously my knowledge is limited, but there are some easy questions I've chimed in on. I don't want to step on anyone's toes, though. Are there any general rules or am I free to use my own judgment?

You are free to use your own judgement and offer your own ideas....just like everyone else is.