ASV vs CPAP etc. for OSA - greater tolerability ???

Long history story short: I tried and failed past attempts at CPAP/APAP/BiPAP. I am a small female with mild to moderate OSA (Diagnosed in 2008) and presumed UARS. I CANNOT tolerate exhaling against pressure, was NEVER - and I mean NEVER - able to fall asleep with any machine, so gave up and have no machine. (Respectfully, please don't give advice on how to "make it work" - I've heard it, tried it, didn't work.) Numerous dental MAD devices have proven fruitless for various reasons I won't waste space going into.

So here is my inquiry. I am desperate and want to try something again, but I KNOW what DOESN'T work for me. I recently read and listened to this post:
https://doctorstevenpark.com/krakowinsomnia
Although the title says for "insomnia," listening to the entire podcast will reveal that for people who actually turned out to have OSA and/or UARS, Adaptive Servo Ventilation (ASV) machines proved far more tolerable than any other. Dr. Krakow says that patients said they couldn't tolerate CPAP, AutoPAP, BiLevel, Auto BiLevel but in some cases couldn't even tell that the ASV machines were even on and wanted to know why they hadn't been offered to them before! I know there are insurance hurdles involving multiple in-lab sleep tests and qualifying as having CSA (hurdles which I can't make) and some patients have opted to buy them outright.

Does anyone out there have experience using ASV instead of CPAP/APAP/BiPAP for OSA (not CSA) and does ANYONE who uses ASV machines attest to the greater tolerability of those machines than the standard CPAP/APAP/BiPAP machines?

Thanks much.

With your current attitude, nothing is likely to work, ASV can be quite challenging.

And since you don't want any "how to make pap therapy work" proven techniques...

Did you ever use the exhale relief pressure feature on any machine - they are fairly standard now and definitely help.

Julie wrote: ↑

Sat Feb 29, 2020 12:57 pm

Did you ever use the exhale relief pressure feature on any machine - they are fairly standard now and definitely help.

reneevanv wrote: ↑

Fri Feb 28, 2020 1:43 pm

I CANNOT tolerate exhaling against pressure, was NEVER - and I mean NEVER - able to fall asleep with any machine, so gave up and have no machine. (Respectfully, please don't give advice on how to "make it work" - I've heard it, tried it, didn't work.)

Nearly 12 years, TMJ, 3 posts.
It does appear you "tried".
Now might be the time to "really lean into it."
If you can.
Cpap is the best we have.
Decades ago, the only hope was a tracheostomy.
Not ideal, by far.
I wish/doubt/am saddened.

chunkyfrog wrote: ↑

Sat Feb 29, 2020 2:00 pm

Nearly 12 years, TMJ, 3 posts.
It does appear you "tried".

Probably misspelled "tired" as "tried".

I heard that the pain of TMJ can make one impatient and unreasonable.
My colleague who had it was intelligent and logical--
but when she was suffering, it all went out the window.

chunkyfrog wrote: ↑

Sat Feb 29, 2020 2:51 pm

I heard that the pain of TMJ can make one impatient and unreasonable.
My colleague who had it was intelligent and logical--
but when she was suffering, it all went out the window.

That's pretty much the thing with most pain.

I know . . .

Wow! The reason I always hesitate to post on any kind of health site has just been demonstrated. "Impatient and unreasonable" because of pain? An "attitude"? Those kind of comments don't exactly encourage anyone. My statement "Respectfully, please don't give advice on how to make it work, etc." was not intended to annoy anyone, but merely to try to keep any answers specifically to my questions. I didn't want the post clogged up with all the usual advice (which happens on most health related forums) since I've read all of that repeatedly over the years and none of it was successful at helping me even though I did try the "proven techniques" and still couldn't fall asleep. I went through myriad masks too. Finally found one as comfortable as could be the last time I tried CPAP, but still couldn't tolerate pressure and could not fall asleep. There is a reason that less than 50% of people who try CPAP can tolerate it or stick to it... and no, it isn't that all those fine people didn't "really lean into it." Believe me, I wanted it to "work" - initially didn't think it would be that hard - but found out just how hard it is!

Palerider: "Attitude" comment aside, thank you for at least specifically stating that ASV can be quite challenging. If that is the case, then I undoubtedly would not be able to tolerate that either. But again, my question was because of the information I got from Dr. Park's interview with Dr. Krakow which indicated that ASV is LESS challenging than the standard CPAP/BiPAP/AutoPAP. Perhaps that is not the case. That is the information I was seeking.

Julie: Thanks for your reply. By "exhale relief pressure feature" do you mean BiPAP? If so, then yes, I had a machine that offered that, but I still couldn't tolerate the pressure - either inhalation or exhalation... even when set to the lowest possible. If you are referring to some other newer feature that I'm not aware of, I would be interested in hearing about it.

Regarding pain, yes I have a lot of it... and not just TMJ, which comes and goes. I have chronic daily migraines with a whole host of associated symptoms, including nausea. That does NOT make a person "unreasonable," but it does make it difficult to deal with anything extra. But I have also read that some people have their migraines resolve when their sleep apnea is successfully treated... which is why I am once again even considering trying anything PAP.

Now, is there anyone out there who can tell me anything specifically related to my question of tolerability of ASV vs any other kind of PAP? I need to know if it is worth pursuing or not. ...Or if in the last few years some super new feature has come out on standard machines that makes them vastly more tolerable, I would be interested in that too (but I haven't seen that from my own searching).

Thanks.

I'm on ASV and after you get use to it,it's just like normal breathing unless you have a apnea then it's wham the pressure goes up real fast and then drops off real quick and your back to normal breathing. It's that wham that you have to get use to but after awhile you never notice it cause it's up and down so fast. I've been on ASV for 8 years and when the pressure goes up and down during the night I don't feel it. You just have to stick with it and you'll get use to it. I wish you well.

ASV machines are nothing more than auto adjusting bilevel machines that have some special functions available to help people with central apnea when they need a LOT more pressure very quickly so that the machine breathes for them.
Without having access to why you can't exhale against any pressure even the minimum with a bilevel machine it's impossible to know if you would do better with it but in all honesty....I have my doubts.
At the end of the day it is still a bilevel machine and still requires you to exhale against some sort of minimum pressure.

I'm mostly a lurker on this forum and seldom comment, but maybe my experience will help enlighten on the ASV use.
I was diagnosed with moderate sleep apnea via a home sleep test in 2017. I was then scheduled for a titration night at a local sleep lab. I think the machine used was some model of Respironics APAP. It was a very miserable night struggling to exhale against the pressure. I left the lab in the morning feeling very apprehensive, thinking I didn't know how I would every get used to breathing that way when it was so hard to exhale in my sleep. I actually was relieved a few days later when the lab called and said I flunked the titration. But they then said the sleep doctor diagnosed complex apnea with both obstructive and central apneas, and they scheduled me for a second night of titration with what they called a bi-level machine. That night went a little better for me, and I went home with a prescription for a Resmed Aircurve 10 ASV.

Experience with the ASV? First month or so it would frequently wake me up with a large blast of air just as I was going to sleep. I think that is pretty common. Since then I have found that if I put the mask on, turn on the machine, and then very consciously take slow, deep, regular breaths, the machine will get in sync very quickly and I'm sleeping within a couple of minutes.

The other problem with ASV is mask fit. The larger the cushion, the more of a "bellows effect" that you will feel with the every breath up and down of the pressure. I've tried 4 different full face masks without success. I can't stop the leaking with those masks. With nasal pillows or under nose cradle nasal masks the feeling is much more natural. Can't feel the "bellows effect" then and the mask will stay in place better. It feels very natural most of the time. If there is a night where I have more nasal congestion, the flow limits will be higher, and I may wake up with the machine trying to force me to breath deeper and faster than I think is comfortable for sleep. Usually then I can get up, clear my nose one way or another, and then go back to sleep. To use the nasal or pillows masks, you have to be comfortable with them on or under your nose, and you have to be able to control mouth breathing.

When I look at my ASV settings I can see that my minimum exhalation pressure is set at 5, but with the pressure support settings and inhalation pressure being quite a bit higher, I don't feel the pressure on exhaling. Usually, the breathing for me feels very natural and I really like my ASV. My nightly AHI is usually 0.0.

Of course, we have no idea what your actual apnea condition is, so there is no way of knowing if your experience would be similar, or whether ASV would even be appropriate for you.

I'm not aware that bipaps have exhalation relief features or not and I wouldn't just assume that, so I'd look carefully at the machine you have for it - or else do a forum search for 'EPR' and see the posts about it. It really works for many people - set from 1-3 (or ?) and will often show a slightly AHI when using it, but that's also made up for in better sleep otherwise.

Julie,

A BiLevel has exhale relief by nature of having two different pressures one for inhale ipap and exhale Epap the difference between the two can be greater than the value of 3 offered by a Resmed Autoset and EPR.