10+ CA's and a bad "doctor". Left to fend for myself, should I ASV, ST, or CPAP?

[Akeyla]

@Jay51 You mentioed:

'Tidal volume looks very high (unless you are a very tall person)'

My answer, I'm generally considrered "tall", but not "very tall".  6'1" (1.85M) , 190lb (86kg), Caucasion male.

And again I really wanted to thank you both.  Next couple next will compare the hack vs real machines.

[Akeyla]

So last night while getting ready for bed, washing my face and mask, I tore the nose area of my new P&K Vitera mask.  Since the mask came with all three sizes, I tried the large for a couple hours which gave me a lot of leaks, enough leaking noise to even wake the wife.  Then I tried the Small mask for a couple hours, (the swap took place right around midnight where it goes offline) and still had some leaking, not as bad, but annoying and it didn't fit well regardless. 

Switched back to my P30 mask at that point for the rest of the night.  So quite the night.  I already have re  placement P&K masks seals on order, should be here this week.   Seemed to sleep well enough using the P30, but it's not the one I want to use long term.

Thinking that I should put my testing on hold until my replacement P&K's get here just for consistency.

[Jay51]

Thank you for posting those Akeyla.  It might be better to wait for the replacement cushions so the testing would be more accurate.  

Tidal Volume Calculator (omnicalculator.com)

By using this online tidal volume calculator I put in 6'1 inches and got 479 to 639 as the average tidal volume for a 6'1 male.  So roughly in the 500 something.  You may exceptional lung capacity (from exercise, etc.) that may be the reason for the high tidal volume.  

This data looks fairly accurate to me except one statistic:  your expiratory time median is 4.26  This seems to be skewed (way too long - at least double normal).  Looking at your close up chart, you do stay at the zero line in your waveform for a long time it seems.  Maybe it is calculating all of that time as expiratory time.  Not to worry though.  

Having a respiratory rate as low as you have (single digits for median) is usually a problem.  But your exceptionally high tidal volume makes up for it.  Respiratory rate x tidal volume = minute ventilation.  Your minute ventilation is acceptable though, so this is the way you breathe for some reason.  

780 x 8.2 = 6.5 minute vent average.  
500 x 15 =  7.5 minute ventilation average.  15 or so is about a normal respiratory rate during the night.  Around 500 is a rough normal tidal volume for males your height.   
You are a little low IMO on minute ventilation median for your height, but not super low.  How do you feel when you wake up in the morning?  Good?  This may help determine if your therapy is satisfactory for you also.

[Akeyla]

So finally, my replacement cushions have arrived.  Instead of going back into my ASV attempts I wanted to try something different.  After my in-lab sleep exam the MD decided that CPAP at 7cm was what they thought would be the best setting for me to use.  I was very groggy the other day so I thought I would for the sake of data give his suggested settings another try.  These charts are from a brand-new AirSense 10 AutoSet running in straight CPAP mode at 7cm.  
 
Also note that I tried using a VCOM last night since it was just CPAP.  Perhaps that's what might be creating the tiny changes in mask pressure when zooming in on an area?
 
You can see there are a fair number of CA's and overall, not great results.  Felt like garbage this morning but has got better as the day goes on.  These are the CA's the doc assures me will go away with consistent use.  The half hour break before this was me waking up, didn't feel super tired anymore, and decided to look at the previous hours data in Oscar.  Wasn't pleased, almost switched to ASV, but decided to stick it out for a night.
 
The 3:00 - 4:30 break, IDK, woke up at 4:30 mask half on.  Think I got up to pee and fell back asleep before getting it strapped back on.
 
Note, the time is off by 2 hours on the CPAP, as mentioned literally brand new just bought an extra, so I'll set it.
 
Tonight, I'm going to go back to the previously suggested ASV settings although I'm going to use the actual ASV system instead of the ASV flashed VAUTO.  I believe I mentioned this before, I am on Suboxone, which could be causing the CA's.  I also take an RX Benzo for anxiety.  Yes, I know, I'm a mess.  (And an antidepressant, but that's been stable for some time).  Regarding @Jay51 mentioning my respiratory rates, I don't know if the meds might play into that.
 
You all are great for taking time to help a stranger on the internet, thank you again.  It means a lot to me that people are out there willing to help.

[Jay51]

Thank you for posting those charts.  Just one thing.  I have read here at ApneaBoard the posts of several members that have used the VCOM.  It can skew results, so your charts are most likely different than using straight cpap without the vcom.  It increases pressure a bit on exhale and actually lowers it a little bit on the inhale I think.

[Akeyla]

The previous night I used an AirSense in CPAP, but my insurance provided machine is an AirCurve, and gotta hit those required days, so that’s what I used last night, in CPAP mode, still 7cm, this time without the VCOM.  Similar results, higher AHI than the previous day, lots of CA's, removing the VCOM does seem to have flattened out the pressure line when zoomed into a specific area.
 
The thing is, I believe the past couple days I've felt somewhat more alert. Still feel like trash when I get up, but more alive during the day.  We’ll see how today goes.  Considering giving this a week, then trying ASV again, though using the actual ASV machine not a flashed version.
 
Doctor tells me that if I stick at this pressure for 90 days, the CA's organically go away.  Is there truth to this? Mind that I take Suboxone (an opioid).  I'll suffer the 90 days if it means I'll get there, I just don't think she knows WTF she’s talking about.  Have an appointment with another clinic, like five months out, and getting all my sleep reports and data from doc.
 
Today I give a 5/10.

[SarcasticDave94]

Given the consistency of CA, the real ASV is the best answer.

ASV does have a CPAP mode, but it's a static single pressure. There's no variables, set one pressure and that's it.

On the aspect of the doctor says CA will diminish in time... You've been on therapy how long?

Also I think you'll need to stick with one machine, settings, etc. to really get results from therapy.

If the DME supplied machine isn't the ASV, return it. It matters little if you use it to meet compliance to keep and pay for it, while being the wrong therapy.

You might use the ASV you purchased to prove necessity to a doctor. Suggested wishlist is replace the doctor that's been about useless. Even your primary or dentist can script CPAP equipment if they're willing.

[Akeyla]

 

• Started March 13th, was on AutoSet with some small changes here and there through May 1st.
  
• May 2nd I convinced them to let me try BiPap.  May 2nd - May 16th it was the same thing, constant CA's, no change in how I felt or how I slept.
  
• Note, on May 12 I used a hacked AirSense in ASVAuto Mode, and yeah, I slept a lot better. 
  
• May 14th was in-lab sleep test.  Had the results May 16th, was told that 7cm CPAP is ideal for me.
  
• I tried it for one day, May 16th, felt horrid, and said no more.
  
• Then May 17th - May 30th was ASVAuto on AirCurve VAuto.
  
• Two days ago I used a literally brand new AirSense AutoSet,
  
• Last night AirCurve 10 in CPAP 7mm so I get the ‘credit’
  

 
Still want to reiterate, none of the firmware I’m using is “patched”, it’s all pulled directly from actual machines I own, and flashed onto different ones.  (The original ASV has never been flashed, just had its firmware dumped as it’s too precious to me to risk screwing up)

You did get me thinking about something though.  Perhaps I should just return the AirCurve 10 VAuto to the DME and use my ASV for a few months.  I have a referral to a much more reputable hospital, although it’s a bit of a drive, would be worth it if things worked out.  My appointment is months out, but I’d have a lot more data to go on by then as well to get proper help.

As always, thank you.

[Akeyla]

Been too long, cannot edit previous post, but the line
May 17th - May 30th was ASVAuto on AirCurve VAuto.
Should have been
May 17th - July 29th.
Regardless.

[SarcasticDave94]

The majority that suffer from what your doctor thinks will diminish over time is called treatment emergent Central Apnea, and this more likely would be diminishing now after 3.5 months. Dr. McQuack just isn't knowledge enough, or has too much ego on the line, to realize therapy needs to change in order to address the CA. I'd jump at the opportunity to get treated elsewhere if I'm in your situation.

I've forgotten, did you get your detailed test results? If not yet, play the HIPAA law card. They must provide it upon patient request. If they refuse, report doctor to the local or regional medical board.