ResMed AirCurve 10 VAuto vs ASV to Treat Central Apnea

[waldo1945]

This is my first post. I have found the Apneaboard the most detailed and useful site for my purposes compared to others on the Internet.  Sleepyhead is pointing out that I am experiencing central apnea clusters of up to 30 an hour with my Resmed AirCurve Vauto Bpap machine (see attached April 2018 screen capture).  Many are lasting 30 seconds. All other apnea types have been mostly excluded by using this machine.  These clusters occur about eight days a month which inflate the average statistics provided by the machine display.   To me, this makes the machine look like it is doing a worse job than reality but the statistics do flag that a problem exists. I visit my pulmonologist in June to determine if he wants to change the machine settings.  I hope to have more information for him as I continue to make adjustments.
 
While my machine is not designed to resolve central apneas, I have read posts on this string that some folks have had success by optimizing the settings.  I have switched from fixed Bpap mode to Vauto mode in order to use the machine’s algorithm.  I widened the pressure range from the 11 to 15 recommended by my sleep study to 8 to 15.  Based on information provided by this string, I have adjusted the inspiration sensitivity (Triggering) and associated Cycle to very high. I have also adjusted the inspiration time range (Ti) to 0.8 and 1.5 seconds respectively based on guidance provided by the clinical manual.  During the past nine nights use, clusters of central apneas are no longer occurring.  The Pressure Relief remains at the initial setup of 4 with no ramp.  Of interest, the machine is determining a pressure range of between 8 and 14 which is lower than the sleep study recommended (See attached May 2018 Results).  Time will tell if this desired trend continues. I have purchased a Contec CMS50D+ for $30 which will give me the blood oxygen saturation level feed into Sleepyhead since I am concerned that the 1.5 second setting is terminating my normal inspiration time too soon.
 
One of the contributors on this string changed to S mode with similar settings on this machine with similar results.  The ability to adjust the triggering and cycle for switching between inhalation and exhalation and the inspiration duration appear to be the key parameters toward success.  It seems like these four settings are providing a pseudo backup breathing rate mimicking what ASV type machines provide in a more direct manner.  Beware; I am just a tinkering engineer and not a doctor.

[Sleeprider]

Waldo, it appears you may need ASV therapy for the central apnea. I we could get a better picture of your settings and results my recommendation is going to be fixed pressure at the lowest pressure you tolerate without causing obstructive apnea, and turn off all pressure support. It's a little hard to tell what your current settings are, but your pressure support appears to be at least 5-cm. That alone will increase your central apnea quite a bit.

I'm going to ask for your post to be moved to a new thread so we can give you some individual attention. Note my signature link on how to organize a Sleepyhead chart. The information there will help us much more.

[ShaunBlake]

Hi, waldo1945, welcome to the forum!

You've done great and seem to be very knowledgeable; good job on educating yourself so well.  I'm looking forward to reading your posts and following your progress as you fine-tune your treatment.

[waldo1945]

I have added the screenshot that you requested to show my current settings, at least those that are logged by sleepyhead.  I have also added my titration summary for background.  The first set of graphs that I supplied for April in my previous post were with the recommended settings from the titration study.  They resulted in the cluster central apneas eight days out of the month that I am trying to eliminate.  The second screen shot that I provided in my previous post was for my current settings after I have been adjusting the machine.  Those previous May settings are identical to the current attached sleepyhead screenshot.  I have intentionally not adjusted the Pressure Relief as the sleep study was done by the pulmonary doctor that I will be seeing in June and he wanted the PR of 4 (the difference between 11 and 15).  So far, I have been able to stop the cluster central apneas without reducing the PR.  The point of my previous post was that the machine I have seems to be more sophisticated than other BPAP machines and may be able to deal with central apneas without lowering or eliminating the pressure relief.  I thought about posting on the thread about cluster central apneas but decided to start with the thread which asked about the capabilities of this specific machine.  The original intent of this thread seemed like it was asking whether this less expensive machine can reduce or stop central apneas without the cost of the gold standard ASV.  So far,maybe it can.  But I am willing to follow your guidance on future machine settings to see what happens.  Maybe I can be your 10,000th post as we discuss further!  Thank you for your dedication to this site ;-)

PS For some reason, sleepyhead is not seeing that I am running the climate control heated hose in automatic.

[waldo1945]

I think I am going to defer to some excellent advice given by several Apneaboard members on this string.  First, I do have good insurance coverage so getting an ASV machine prescribed at a relatively low cost to me is possible to eliminate my central apneas.  Second, my heart ejection fraction is 65% which is well over the 45% cutoff to deny prescribing an ASV machine.  (Please see the attached slide discussing the heart ejection fraction limitation) Third, getting my current machine to handle central apneas works against getting my doctor to prescribe an ASV machine.  So I switched back to the original prescription settings on my machine so that my trip to the doctor next month will be using data that will support getting an ASV machine. (my central apneas immediately increased) My doctor wants to review the “history” saved on the machine to guide his future recommendations. There is time after my June 14th doctor’s appointment to try some alternative settings with my current machine for the sake of gaining knowledge on how to best set the AirCurve 10 Vauto to handle central apneas in my case.  I am still interested in pursuing how to best set the AirCurve 10 Vauto for those people who may not have any other choice but to use this machine to try and reduce their central apneas or for me if an ASV machine is denied.
 
This is an update after receiving and using the finger blood oxy measuring device that I mentioned in my first post.  The attached file shows the return of my cluster central apneas after resetting my machine to the original prescription settings.  In this case my blood oxygenation level ranged between 78% and 85% until I woke up feeling drowsy.  It took about ten minutes of normal breathing to get my blood oxygen back up to the 96% range and feeling human again.  This is definitely not a good situation. My dilemma is to keep the prescription settings that appear to be causing the cluster central apneas so that the machine history will support getting an ASV device or use settings that seem to eliminate these cluster central apneas that appear detrimental to my health and plead my case using the attached and previous screenshots showing the cluster central apneas with the prescription settings?  I think I am going to use my settings and plead my case with the screenshots. I don't feel comfortable using settings that seem to be forcing cluster central apneas.

[Sleeprider]

Waldo, your AHI "seems" very good in this screenshot, but your therapy is full of periodic breathing which suggests the underlying central apnea is still a problem. Zoom in on your respiratory flow rate and you will see the rest of the story. ASV would smooth out the periodic breathing pattern which oscillates between 20 and 55 mL/sec. The Aircurve 10 Vauto has no therapeutic application to central apnea and your problem remains unresolved in spite of low AHI. Hopefully your doctor is motivated and qualified to see this. One-hour and 20 minutes of therapy isn't much, but I can understand that is it probably uncomfortable and not giving you the relief you need. Were you sleeping?

[waldo1945]

Thank you for your latest response.  I will take in good faith that my current machine has no central apnea therapeutic effect and will push for an ASV machine.  Yes I was asleep during the reported time period.  I am retired and have no regular sleep schedule. I rarely get more than two hours of sleep at a time and always use my machine unless I accidently doze off for awhile.  All my pulmonary doctor wants to see from me during my appointment next month is my machine.  He does not care about whether it has an SD card or not.  Since the data stored on the machine is just average summary data, my cluster central apneas are going to be buried in the averages.  So it is up to me to bring the screen shots to him and show that my blood oxygen level is dropping below the magical clinical 88% during the cluster apneas and causes me to wake up.  The clusters last from 10 to 30 seconds each one right after the other until I awaken. He already knows about my erratic sleep schedule.  I wear a FITBIT watch which collects the attached REM sleep information which I will add to what I show the doctor. If I can't convince him to prescribe an ASV machine with my acceptable 65% heart ejection fraction, I will ask my long time general practitioner to do so.  Thank you for sharing your expertise and helping me solidify a plan to get an ASV machine.

[JesseLee]

Thank you for your latest response.  I will take in good faith that my current machine has no central apnea therapeutic effect and will push for an ASV machine.  Yes I was asleep during the reported time period.  I am retired and have no regular sleep schedule. I rarely get more than two hours of sleep at a time and always use my machine unless I accidently doze off for awhile.  All my pulmonary doctor wants to see from me during my appointment next month is my machine.  He does not care about whether it has an SD card or not.  Since the data stored on the machine is just average summary data, my cluster central apneas are going to be buried in the averages.  So it is up to me to bring the screen shots to him and show that my blood oxygen level is dropping below the magical clinical 88% during the cluster apneas and causes me to wake up.  The clusters last from 10 to 30 seconds each one right after the other until I awaken. He already knows about my erratic sleep schedule.  I wear a FITBIT watch which collects the attached REM sleep information which I will add to what I show the doctor. If I can't convince him to prescribe an ASV machine with my acceptable 65% heart ejection fraction, I will ask my long time general practitioner to do so.  Thank you for sharing your expertise and helping me solidify a plan to get an ASV machine.

Going in armed with information is critical. I like the idea that you have about asking your general practitioner to write a prescription for you. I find that talking to my family doc is a lot easier than dealing with a specialist. I have written down exactly what I want him to write me a prescription for, and after a brief discussion, he has always written the prescription. If you have your prescription for your CPAP machine, you might consider copying the prescription and making notes on the copy, replacing the details with precisely the machine you would like. For example, "Dispense Resmed Aircurve 10 ASV with heated tubing and humidifier....99 months..." "include mask of choice..." 

Your coverage provider might not pick up the tab on the machine but with some careful maneuvering you may be able to get your equipment provider to accept compliance with the ASV machine and your coverage provider can help with supplies. 

I'm prescribed an auto CPAP and use an auto Bilevel machine that I bought on my own and the supplies are covered by my insurance despite my use of a machine not specifically prescribed.

[Sleeprider]

It's pretty common for central apnea patients to have very inconsistent results. This often makes it difficult to diagnose and titrate in a limited time clinical setting. What I wanted to point out in your last chart was the variable (periodic) breathing. This can often turn into a series of CA, but this time it didn't. I think once you have appropriate therapy that you will be able to sleep better and establish better routines.

Have you ever experimented with fixed pressure without EPR? I think if you tried a pressure of 8.6 fixed CPAP with no EPR you might actually get some surprisingly good results.

[waldo1945]

Jesselee, I like your suggestion of working up a sample ASV prescription for my doctor.  I tried to attached my current prescription from my general practitioner with my BPAP information crossed out and information added for an ASV machine but the PDF was too large. I don't know if another sleep study is usually required at this point (after using a BPAP for a year and still experiencing central apneas) to get the recommended ASV settings or if we can just fill in some reasonable numbers as I have tried to do. Any guidance about filling in recommended ASV settings would be appreciated.  I currently filled in EEP of 25 and Max Pressure Support of 19 and Min Pressure Support of 4 with Default backup rate.

For Sleeprider, I had been using a CPAP with a setting of 10 with no EPR for ten years prior to getting this AirCurve 10 Vauto a year ago.  My old machine did not have the capability to record detailed historical data.  So I could try the CPAP setting of 8.6.   I would like to wait on this until after seeing my pulmonary doctor in June so that my machine settings remain constant until after the appointment unless you see a benefit of trying it now.  I don't want to interfere with building a case for an ASV machine.