beginner ASV & central sleep apnea questions

[absurdlyTired]

I am completely new to this, and have only had 3 nights so far using my Resmed S9 VPAP Adapt (w/humid) & Mirage Quattro full face mask.

I have been setup with an "EEP" of 11. When I spoke with the sleep lab after the first night, she mentioned that we could drop it to 9 for one week, then bump it up to 10 for one week, then back to 11. Apparently, 11 was the number that resulted in a short period of sleep without any central apneas during my 3rd sleep study.

1. What are your thoughts on this tweaking of the pressure in this way to allow someone to adjust? I seemed to get mixed messages from the sleep lab. There was the thought that this might ease my transition, actually allow me to sleep a bit, and minimize my air gulping (and gas). Then it was mentioned that I could decide in a few days whether or not to go this route because it might make sense to stick with 11 if I am making some progress (even if it's slow).

2. Last night, I took a look at the display when my Resmed seemed to be fighting me (or me fighting it) and causing me to hyperventilate a bit. The pressure seemed to go from 11 to 22. Do they have to set the range when they set these machines up? What's odd is that my order (written on my 3rd sleep study results) states, "EEP setting of 11 with Pmin 6 and P max of 15". Should I really be seeing 22? Could this be too high?

3. I bumped up the humidity to 6.0 after experiencing extreme dry mouth and sinus dryness/pain. A couple of hours later, I was having a strange flappy valve sound coming from the area (I think) that connects the tube to the mask. After some inspection, I could see a lot of condensation in the mask and tube. I tried to shake the tube out in the shower, and dried the mask with a paper towel. The sound stopped. My question is - my room is rather cold (heat set at 60 during the night, but I am in coldest room in house near a window). It seems to make sense that this might contribute to the condensation. I'm wondering if getting one of those cloth sleeves for the tube would make a difference. What about these heated tubes I have heard about?

4. I woke up after actually sleeping a bit by sitting straight up and trying to rip my mask off. It felt very similar to a pre-asv "event" where I felt like I was choking/drowning. Shouldn't ASV minimize these types of things, or is it possible that it's just part of my adjustment?

5. I have a history with anxiety/panic. Since experiencing this central sleep apnea (3 months ago), I have avoided all alcohol and stayed away from even a Xanax because I was told it is very dangerous for people with central sleep apnea. Anxiety and panic has been a part of my life now since this happened (apparent onset of central sleep apnea 3 months ago). I'm wondering if this isn't slowing my progress with ASV because I can't seem to "just relax". I am often hyperventilating or feel that the machine is making me do so. So, my question is: Since the ASV device should keep my brain reminded to breathe, how harmful would a tiny dose of Xanax be on a night that seems to be a struggle? I have .25 mg and only usually take it when flying. And even then, I have been known to just take a half pill. Thoughts?

Thanks! Sorry for the long (and probably basic) questions. I am feeling quite awful and sleep deprived. I'm a shell of a person, and I really need this to work for me.

[Xney]

On your VPAP adapt, do you have the heated hose (climateline)? It helps a LOT with condensation issues. There are hose "covers" you can buy which will also help. Not sure about using them together if you already have a climateline.

"Fighting" an ASV is a very common experience. You do start to adjust after a while. Maybe some people with more breathing problems on ASV can comment on it more. I use(d) an ASV, but I was pretty used to bipap by then. I found I just needed ot breathe regularly but not too slowly falling asleep, and then try to ignore the machine. We would eventually sync up.

The VPAP Adapt has three settings related to pressure:

1) The exhale pressure, you can think of that as the "minimum" when you breathe out. For Adapts, always exhale against this pressure, it will never increase.

2) The pressure support, which has a minimum and a maximum. The PS is the amount the pressure will be higher when you inhale. The minimum and maximum are the range the pressure can increase by over your exhale pressure, which the machine adjusts on a breath-by-breath basis.

For example, if you have an exhale pressure of 11, PS minimum of 6, and a PS maximum of 15, it means:

a) when you exhale, the machine will always be at a pressure of 11
b) the minimum pressure you will inhale with is 11 + 6 = 17
c) the maximum pressure you will inhale with is 11 + 15 = 26 (I'm not sure the machine can actually go this high)

It really depends on what your sleep study said, but you may want to try a lower exhale pressure and a smaller range of pressure support to get used to it. Your settings right now could be challenging juts because of the swings, starting out.

You could discuss with your doctor something like:

Exhale = 9
PS min = 4
PS max = 9

This means your exhale pressure would be 9, and your inhale pressure would vary from 4 to 18 as needed.

It's important that your data is looked at, no matter what, once you start getting some sleep on it.

[old64mb]

Hi AbsurdlyTired,

Let me try to answer some of your questions. You may also want to search for some of the ASV threads, since they'll explain a little bit of the theory behind the answers. I presume, by the way, that you have the Adapt SV.

1. EEP doesn't have a lot to do with centrals. It's actually the base pressure you have to splint open your airway to prevent obstructive apneas. If you can eliminate your obstructive apneas at 9 rather than 11, then the lower pressure is fine. If it takes 11 to do so, then you should be at 11. This also points to you likely having complex OSA rather than a predominantly central SA variant; those with the latter tend to have much lower EEPs as there's no obstructive component.

2. In a non-sophisticated nutshell, the actual way the machines eliminate centrals is to provide several pulses, each at higher pressures, to convince your central nervous system that it's time to breathe. A Pmin of 6 and Pmax of 15 on an EEP of 11 means you will have a base IPAP at 17, but that IPAP with those pulses can range all the way up to 26. Thus, seeing 22 is not going to be unusual. Basically, if the machine thinks you're struggling, expect a pressure boost.

3. Search for threads on rainout, since it's the same with the ASV and standard units. Heated tubes are much more effective than tube covers, and I think the S9 has a heated hose that's custom to the unit.

4 and 5. Benzos like Xanax tend to be bad news for central apneas. However, the bright side is that you are now on one of the few machines that is probably capable of coping with any additional centrals that it'd cause, although your MD is going to have to make a call in terms of if that risk is worth the reward.

My suggestion would be to spend a few weeks getting used to the machine as it takes some time to adapt to a very different experience than on traditional xPAP and then if you're still having problems to bring up the possibility of trying Xanax with your MD. Almost everyone reports that they have a bit of trouble adapting to the SV units, but eventually everyone tends to find that after they get used to it they do much better.

Hope that helps.

[NateS]

I skip the slow ramp up and instead take 4 or 5 very deep breaths in and out, which seems to get me and the machine into sync with each other. Then I just relax and start breathing easily and normally - not deeply, trusting my lungs and the machine to be in sympatico. This works best for me, and might for you too.

Regards, Nate

[absurdlyTired]

Thanks everyone! Very informative.

I have ordered the heated tube so I can bump up my humidity to comfortable levels while lowering the risk of rainout.

Also, after an awful night of aerophagia and (what felt like) forced-hyperventilation, I am calling to see if I can lower pressure today.

[Xney]

Good luck, I hope you can get it lowered. Once you get used to it, higher pressure is usually not such a big deal, but it's challenging to start.

I found simple things like gasx work nicely to help with aerophagia being in the stomach in the morning.

[absurdlyTired]

Update - the sleep center called back and said that they highly recommend that I give this pressure some more time. They were concerned - after reviewing my sleep study results - that it might actually make things worse for me to go to 9 or 10 (from 11).
Part of the problem is that I can't see the actual sleep specialist until the beginning of February (note: I was diagnosed with CSA during my first sleep study in November. It's been a struggle to get care - and a coherent vision of who I should see and how this will work). I am now dealing with the sleep center techs, and my primary care physician who had never heard of CSA.

I'm going to buy some Gas X to prep for tonight. Hopefully I can get past that 2-hour mark, where I wake up in agony from the gas. Maybe I can take some before going to sleep.

[Chuck Connors]

absurdlyTired, I can empathize with you. For the first few days of using the ASV machine, I felt severely sleep deprived. My sleep doc then changed the settings on the machine and everything is much better. However, the best sleep I've ever had in my lifetime was while I was staying overnight in the sleep center and they applied the ASV therapy using their machine. I was fully alert and on my game the entire next day. At the follow-up meeting with the doc, he said it would be difficult, if not impossible, to replicate the results of that night in the sleep center due to the technician using various settings throughout the night. However, it leads me to believe that it's only a matter of time before CPAP manufacturers develop a machine which will replicate the results I experienced that night. My sleep is good now, but I may follow the advice of the sleep technician and have another sleep study, but using my own machine this time.

It does bother me somewhat when the doc says, "We consider you treated." There is a difference between the medical standard of "being treated" and having a great night of sleep. -Chuck-

[Xney]

You really DO get used to pressures and such which are impossible at the beginning - that is certainly true.

How does your mask feel to you? It can be challenging to fit a mask with ASV.

[absurdlyTired]

Thanks Xney for the words of encouragement. It's difficult to imagine getting used to this, but I am in such a sleep-deprived state, simply going grocery shopping is becoming a psychedelic and challenging experience of confusion, disorientation, and warps in time.
Yes, the mask seems ok. I had some severe irritation on my nose the first night, but it seems to be slowly clearing up. I have it tight enough that the leaks are minimal as long as I don't do too much.

[Xney]

Masks with an ASV are a challenge, due to the extreme pressure changes. However, you shouldn't have to tighten it down *that* much - keep an eye open for trying a different mask, if it doesn't feel like it fits well. Strapping it down hard enough to hurt or keep you awake is a sign it doesn't fit.

The DME can't lower the pressure without doctor's orders because it will put you below your prescription, i.e., your "medical need". Though I would definitely try to get your doctor to allow it (or another doctor?) if you feel it's getting in the way of your therapy, or adjusting to the therapy.

Each step for me (CPAP, BiPAP, ASV) was an adjustment, but I did eventually make them work for me.

[TheUglyTruth]

Anxiety and panic has been a part of my life now since this happened (apparent onset of central sleep apnea 3 months ago). I'm wondering if this isn't slowing my progress with ASV because I can't seem to "just relax". I am often hyperventilating or feel that the machine is making me do so.

This might be difficult with three children but it could help if implemented:

1. Study (Google is fine) "sleep hygiene" and practice it well.

2. Start a moderate exercise program and stick with it. Choose something easy and convenient (walking in the neighborhood maybe).

3. Eat well - variety of healthy meats, fresh vegetables and a few fresh fruits. Stay away from "empty carbs", soft drinks, sugar, processed foods, salty foods.

Of course these practices are good for perfectly healthy people to follow also.

Based on my experience, if you get the apnea well treated the anxiety may subside or disappear.

I wish you the best.