18 mths of apap: need help optimizing settings to feel better [ASV]

[ajack]

You could be right, the min epap and max ps 9 is enough. I don't know yet, till the charts are up

[sheepless]

"or just increase the min epap till the obstructives are resolved."   ajack, even with the relatively high 0.8 and 0.7 ahi last 2 nights, which amounted to 1 ua and 12 h (in 16.75 hours over 2 nights), some of which may be sleep wake junk, it may be a bit optimistic to expect to resolve the obstructives a whole lot better.  up until a few nights ago my roughly 70 day ahi was 0.21.  not contesting your suggestions, just trying to figure out what we hope to accomplish.

also, I have a different understanding than you with respect to how asv reports or doesn't report ca and oa, but no matter...

here are the same segments as the charts as above in #143 but with the graphs you want and zoomed to a 3 minute view.  these are from SH 1.0.0 beta 2, broken gl.  I haven't used resscan in about a year so it'll take a little work to update and set up.  check these SH graphs out and let me know if you still want data from resscan before I take the time to do that, please.   

next I'm going to attempt to check out and hopefully report how I fared on settings similar to your suggestions that I've tried in the past.

[sheepless]

ajack, et.al., looking at the no collar chart I see more flow limitations than with the collar. I'd love to ditch the collar. different settings might reduce the flow limitations. but then my leaks would increase without the jaw support and with higher pressure so I'm not sure what's to be gained there. still, I'm open to trying things in the quest for restorative sleep.

it's my view that the source of my fragmentation is plm and afaik no machine setting is going to help that. eventually I'll get around to shelling out $350 for a 10 minute office visit to ask for something to ease the plm.

I don't believe it to be true but if the pattern I associate with my plm is instead, say, the machine responding to ca and/or some non-plm form of periodic breathing, then maybe different settings will help that. of course there are no adjustments on the asv designed to address ca and pb. although I wonder if you'd say increasing max ps might. oddly, though, my experience generally has been more events at higher pressures.

just thinking out loud; I'll wait to see what you have to say about the last charts. let me know if want to see anything else.

[sheepless]

"max PS, whatever min-epap+maxps=25 comes out to." ajack, I thought max epap + max ps = max ipap. is that a typo or are you suggesting something different?

another thing after rereading your post #149. I lowered max epap and max ps in large part to avoid aerophagia and increased leaks. when opened up, it would frequently get up to 24+ cmw but for some reason I also seemed to have more events above 21cmw, which is where my max ipap is now. with current settings the machine has rarely gone over 20 and never reaches 21.

I'm hoping you have something cool up your sleeve that's going to resolve all remaining issues :-) and I'm willing to try things but it's hard for me to see what can be improved with pressure. of course I don't know what I don't know!

[ajack]

no the min-epap is what you use to get what the max ps can be in settings. Or simpler, you just dial the max-ps around till it won't go higher. You might want to go one at a time?
Pick Lanky's video up at 13min, he's talking about a philips ASV in his default, the principals are the same. I have said the same before he released this video. I agree with him.
youtube Bilevel and ASV Titrations: Pressure Changes for Technologists and Patients

you can unpin all the charts and it looks like leaks aren't fixed, so that's the first job and put a leak chart up. As you saw in the video, ASV and leaks don't mix. Sort out whether you want to use the collar all the time or not. It's 6 weeks and 16 pages and the basics aren't sorted. Isn't it frustrating for you?

I would change the Y-axis to zoom in on the height, to make it clearer, get rid of the dead space. Tidal volume doesn't need more than 1,000 as a max setting for example.

set the column on the left hand side up as what is normally suggested. show a full length chart for an overview.

I went back to look at your earlier charts. It seems the forum may have a time limit and dumps them? This makes it hard even here. New members could find a wealth of info in the old threads, now that looks like it is going to be lost now, imgur may be the better choice, if the forum doesn't want to get storage..

[sheepless]

ajack, I'm not sure what you are looking at.  on the SH charts I posted in #152 above, tidal volume max on y-axis is 750. last night my 95% was 780 and max 1720 (99%: 1180).  

I'm sorry, I understand changing / apparently reducing the scale of the y-axis but I don't understand zooming in on the height.  I zoomed in from 6 to 3 minute scale but apparently that's not what you had in mind.  do you, for example, want tidal volume max to be say 500?  that will make it clearer? I suppose I could put 2 or 3 on a page and expand them vertically by expanding the box creating more white space.  will that do?

I pm'd you a couple weeks ago about the video you cite and I think I commented in this or another thread about it because what he claims is completely contradictory to my own experience.  I believe open ended settings are good for initial stages of titration (which I believe is what that guy does for a living) but not usually for for fine tuning.  that's been my experience with my machine anyway.  IDK about other people.  

I have a few minutes most nights over redline but my leaks are as well managed as I can.  last 2 nights 99% leak rates were 9.60 and 15.60.  time over redline: 0.065% and 1.854% respectively. I honestly don't know what else I can do short of shaving and finding a completely different mask.  not gonna happen anytime soon.  besides, everything I've read suggests the resmed machines and especially the asv adequately compensate for leaks up to - and to a progressively lesser extent somewhat above - the red line.  

I always, always, always wear the collar.  I cannot pap without it.  I went for a 30 minute nap without it in order to see and post how it looks different in the flow rate. 

I'm attaching the full night chart so you can see it plus the stats on the left of the daily tab.  note that it's from oscar.  the 3 minute charts above were were from SH.

it's been 16 pages but more than a year in this thread.  closing in on 3 years total wrestling apap before asv.  not sure what you mean by 6 weeks.  

I sincerely appreciate your time and effort.  however, I'm not at all unhappy with my settings right now.  

I still don't know what we're trying to accomplish.  until then I'm inclined to sit tight.  

I follow your comments with great interest.  I hope you'll continue to take an interest in my case in future when I post with questions and problems.  

thanks again sir!

[WhyMe]

I would guess the six weeks reference was based on misreading the year your thread started

[sheepless]

whyme, yes, that makes sense. thanks for helping me with that.

[ajack]

I think the Y=axis on tidal is 1750 and the 1 is hard to see. By changing the y-axis, it looks like the chart data is zoomed or widened, without dragging the chart to do it.

Ultimately you and your doctor work out what is best for you. No problem about the video and I remember now. I think lanky knows more than I do and it's not as technical as the youtube seminars on ASV. So it's easy for most people to get their head around. You might find the seminars better. There are a few on this channel https://www.youtube.com/user/emjreviews/videos

The AHI tells us about obstructive. You seemed to think that was the end of it and max PS didn't matter. You could probably even get good AHI with less than max PS9.
I'm trying to help you see if PS9 is enough to treat your CA and other breathing events that min epap doesn't treat. So far there is nothing to indicate that it does treat the CA effectively. You need to find some and see if there is enough mask pressure, tidal volume and minute vent. We don't communicate well and I sense your frustration. You need to do what's right for you.

[sheepless]

ajack, now I think I understand what you're aiming for.

it's been my understanding that ca and csr are handled algorithmically; no settings involved. also that this asv does not pulse or FOT to differentiate between oa vs ca, characterizing all apnea as ua instead. the prevailing thinking is that ua will be all oa but that never sat well with me. if all oa, why not report that?

so you're saying there may be ca among the ua and that max ps has to be high enough to resolve that ca?

still a little confused about how you can say that ahi doesn't account for ca if all apnea events are included in ua.

similarly confused why inadequately treated ca would not show up in ua, if that's what you're saying instead.

I don't get a heck of a lot of ua at current settings so as long as any remaining ca show up as ua, I seem to be doing fine.

still, if I want to rule out untreated ca, how do I search for them? what am I looking for? I've never been very clear on how to distinguish ca and oa in the flow rate. what are the characteristics of ca? if I find any, I assume I should post them according to your display preferences. I guess any I find will by definition not have been treated adequately.

I'm pretty sure I have tried settings similar to what you've suggested thus far. when I have time I will try to find them. meanwhile, I could just bump max ps again for a few days to again see the effect.

it's not that I don't think max ps is important; it's that I tried higher settings and felt I had poorer results. increased events, as well as aerophagia and more leaks.

if I'm going to continue down this path, what do you recommend? is there any reason to reformat the graphs I already posted? or should I try to find past ca in the flow rate at current settings? or bump max ps?

btw, you are right about the 1750 vs what I thought was 750. and I think maybe I get the y-axis thing; we'll see next time I post them.

re my frustration; more than you want to know: I'm closing in on 3 years with cpap. until recently I had been extremely frustrated by insufficient progress as demonstrated by apap numbers before asv and mostly how I still feel. recently I've noticed significant improvements in this regard. it's been a nice change to feel optimistic about my current settings, given my low ahi. I thought I'd accomplished all I can with cpap and any remaining problems (like plm) would have to be dealt with in another way. I didn't really want to consider that I'm still not be there yet. otoh, who doesn't want to do better, so I'm trying to adjust my attitude.

I tend to be wordy, poking around trying to understand this stuff. I'm still not convinced there are improvements to be had but I can see how it would be useful to rule out/in residual ca. sorry if I sound difficult or argumentative; it's how I learn. bear with me.