2 weeks on new ResMes ASV, need some opinions/ advice

[RickEiben]

Newer user on this forum. A little history first. I'm a 68 yr old male, 6'-2, 190 lbs. Had my 1st sleep study (SS) done at 50. Mild OSA sleep apnea, AHI 2.4, worse on my back, snoring, O2 sat 89%. Nothing done. 
 
2nd SS done at 56, same results, nothing done. Both show mild Atrial Fib, which I still have.

 3rd & 4th SS done last year, AHI of 15.4, O2 sat of 82%, and was put on a ResMed Air Curve 10 ST for about 6 months,  Pressure at 19/14. Had pretty good AHI, all below 5. Everything I read says this is normal...I'm not buying it. At this point, I got control of the settings, did a lot of reading, and got quite an education on cause and effect of the various settings. Finally got tired of continually changing the multitude of settings, and thought the auto ASV would be better. Never could get a comfortable mask for high pressures, which continues to this day, and still waiting for that magical moment when I suddenly feel better. A 5th SS Titration was done recently for auto ASV, and got one 2 months later, covered by Medicare.

While waiting for the ASV, I acquired a 2021 Philips Dreamstation auto CPAP from the recall and used it for 2 weeks with good AHI results below 2 or 3. Best settings were 13.5/17-18, flex on C-1 and on auto mode. I really like this machine.

I'm including 3 graphs, and will send 2 more that I want you to see next time. The very first one dated May 3rd. That and May 9th. are at the prescription setting of 4/15 EPAP and 4-20 PS. May 11th is 8/15 and 4/15. I need to get the settings dialed in, but more importantly, feel better. Thanks so much.

[Sleeprider]

Hi Rick, I missed this when it was posted, so thanks for the PM heads-up. If you had continued with the original thread, please know I follow threads where I have previously responded, so it is very likely I may miss a new one or not recognize you as someone I have worked with before.  The reason we have asked that therapy threads be kept together is that the history is important, especially in cases like this.  Please keep your therapy related posts in this thread and do not start new ones, or I may again miss it, and certainly will not do another multiple thread search to figure out what is going on.

With that said, in your first thread https://www.apneaboard.com/forums/Thread...r-2-months we were discussing using your VPAP ST machine with central apnea.  Unfortunately, we never got an Oscar chart on that thread, so other than a conversation about complex sleep apnea, we didn't have much to work with, however it was pointed out that if central apnea is present that ASV would be a better solution. 

You apparently acquired an ASV and started threads on your initial settings https://www.apneaboard.com/forums/Thread...to-machine
and mask fit with ASV https://www.apneaboard.com/forums/Thread...rve-10-ASV
and finally also posted your results using a Philips Auto CPAP https://www.apneaboard.com/forums/Thread...s-in-OSCAR  In this last thread, we finally got a look at your therapy.  The outstanding characteristic of Auto CPAP was the positional apnea as indicated by heavy clusters of obstructive sleep apnea.  I missed this last thread and would have advised higher minimum pressure and correction for the obvious positional obstructions.  It's worth noting, very little evidence of central apnea events.  That thread sort of devolved into some technical issue of acquiring more useful data and you did not get appropriate coaching for the obvious problem shown here:



That brings us to this current thread where you have posted three graphs with the ASV.  I think this one tells us all we need to know for the moment, and that is your positional apnea continues to be an issue and is the first thing we need to address.  Positional Apnea  is a very common problem and we have seen examples of it with many members on all types of machines including ASV.  You either need to address issues like too many pillows or related sleep positions that cause chin-tuck, or you will need a Soft Cervical Collar. 
[url=https://www.apneaboard.com/wiki/index.php?title=Soft_Cervical_Collar][/url]
Your current settings are EPAP min 4.0, EPAP max 15.0, PS min 3.0, PS max 15.0. Let's increase EPAP min to 6.0 and work on the positional apnea.

[RickEiben]

Thank you for responding Sleeprider. My apologies about the multiple threads, I will use only this one from now on - novice error. Since finally installing Oscar and trying to figure out how to use it, I realized another error - the SD card in the ST machine that was returned. I called them yesterday about it, and they are looking for it. I'm sending 3 more screenshots, all at the prescribed setting of 4/15 and 4/20 PS. The last one is last night, which had 0 apneas and only hypopneas, the lowest AHI to date. It also had the lowest readings of EPAP and PS to date.  WOW!  (I drank a soda 2 hrs. before therapy, something I rarely do. This happened 1 other time with a very low AHI. Probably a coincidence... just saying) I'm going to keep this setting for at least a week to establish come continuity, which has been hard given my propensity for changing settings almost daily. I do have 3 other charts where the EPAP was raised to 8 and the PS lowered to 15. Also of note since starting this ASV machine is 0 obstructive apneas. I will also send an expanded screenshot later if you want that I believe shows Cheyne-Stokes Respiration. Biggest issue to date is the tight mask fit needed. I'm also a side sleeper, and usually get woken up twice at night to use the bathroom. Thanks again!

[Sleeprider]

The ASV does not flag OA, it flags UA because it doesn't use the FOT (forced oscillation technique) to distinguish obstructive from central apnea. All UA are assuemed to be obstructive because if it doesn't respond to the 15-cm of pressure support, the airway is obstructed not clear. You have episodes of positional apnea.

[RickEiben]

Thank you for the diagnosis! I went back and looked at the Philips auto CPAP data - lots of OA and very few, but occasional CA's. I'm going to get a cervical collar but tried a  different side  sleeping technique last night in the mean time. It worked! I pulled the corner of the pillow down and under my tilted up chin, it stayed there until rolling over. Did the same thing on the other side. see attached screenshot. I'll try it a few more nights to confirm its effectiveness.

[RickEiben]

Hope I'm doing this right... I wanted to add another screenshot of the same night using the requested OSCAR standard view charts for review.

[Sleeprider]

Rick, your therapy looks great since you started taking measures to prevent the positional issues. I often use the corner of my down pillow between my shoulder and jaw, and it can really help with position and leaks. Seems to be going well. There is an interesting inverse relationship between respiration rate and pressure.

[RickEiben]

Well, not the same results as last night. See the 3 screenshots below. The first one that occurred (middle one) was due to a very loose mask - put a different one on for the other 2. I turned the PS down to 3/12 for the 1st & 3rd. screenshots - bad habit. I'll turn it back up to 4/20 & continue this experiment.  Will be ordering a collar today. Not sure whether to get the Velpeau comfort version, the dual use, or the enhanced. ??

[RickEiben]

I went shopping yesterday in town for cervical collars. I found 4... they were all too short, and would not work at all. I was going to order a Velpeau enhanced version XL, but the website only takes Pay Pal, not my CC. So I made homemade cervical collar out of an old pair of ski goggles and foam pipe insulation mounted on the top and bottom - worked great. As usual, it worked best with the indent for the chin (opening for the nose on the goggle) upside down. It's 4 1/2" tall, uses the goggle strap on the sides and back, so it's not hot, and does not interfere with anything while sleeping. Very easy to make.

The difference was night and day when looking at the AHI - 0.3 and the AI - 0.0. The charts are just like Sleepriders before and after charts. Thank you Sleeprider for diagnosing the chin tuck positional apnea !!  

The next step, if this trend stays on track next week, is to make some adjustments to control the respiration/breathing and lower the pressure slowly so the mask is more comfortable, while keeping the numbers low.

Below are the before and after charts. There is hope.

[Sleeprider]

Wow! That's great and very innovative. It doesn't matter how you avoid chin-tucking, just that you do it. The ASV is still working with pressure support to deal with central events and working well. Post of the day in my opinion. Well done!