ASV Machine

[Sleeprider]

Congrats on the outcome of your long-term effort. FERC and energy corridor permitting is very complex and seems to go on for years. I am usually on the other side of the table, trying to obtain approvals, so I'll assume your case must have been compelling to require a re-route or denial.

I think using this default titration setting has advantages. It is what the manufacturer recommends as a starting point for ASV titration, and will give us information starting from the lowest possible starting point. Your study was frankly not very useful, so your doctor's conclusion is understandable, but it's a good thing he approved ASV. You are on the right track, and worst-case, we end up back at your original settings which are a big improvement from what you experienced before ASV. If pressures seem to go too high, and you need to sleep, cut the PS max to 10.

[Spy Car]

Congrats on the outcome of your long-term effort.  FERC and energy corridor permitting is very complex and seems to go on for years.  I am usually on the other side of the table, trying to obtain approvals, so I'll assume your case must have been compelling to require a re-route or denial.

I think using this default titration setting has advantages.  It is what the manufacturer recommends as a starting point for ASV titration, and will give us information starting from the lowest possible starting point.  Your study was frankly not very useful, so your doctor's conclusion is understandable, but it's a good thing he approved ASV.  You are on the right track, and worst-case, we end up back at your original settings which are a big improvement from what you experienced before ASV.  If pressures seem to go too high, and you need to sleep, cut the PS max to 10.

Bolding this last as my personal experience on the first (and only) night using IPAP Max 15 and PS Max 15 was that it produced levels of pressure that certainly did make sleeping impossible, so glad you mention the possibility to Larry.

Bill

[ajack]

The machine needs what it needs, 15 is in the lab titration default. It may need more than 15, it may need less. No one can predict what this number will be, everyone is different. We know 7 isn't working by the stats and chart. I have no issues with using 10 for a week, then 12 then 14 then 16, etc. till you can see that the machine is properly titrated and not needing more PS. You need to use the pressure stats, minute vent, tidal volumes and flow and pressure chart. The UA/H are redundant once the epap and min PS is sorted. You can have AHI 0.0 and still be poorly treated.

It really is a matter of getting use to it. In the short term choking the machine back doesn't hurt. Where the problem is that the user keeps it there and doesn't allow the machine algorithm to do it's job. What pressure have you built up to now spy car?

[LarryRapp]

Here is last night which was EPAP min 5, EPAP max 15, PS min 3, PS max 15.  I may want to cut down PS max - I can stand it, but I don't like it.

[Spy Car]

 What pressure have you built up to now spy car?

I'd been doing so well that my pressures have been static. The numbers have been good and (and, critically, I've been sleeping well and feeling great).

However, the past week has been less good. The AHIs have been fine, and no insomnia, but I'm not feeling very refreshed. I will try to post charts in my thread soon to see if there are any clues to what might be going on.

I tend to dislike the feeling of high pressures but am open to making changes.

Bill

[ajack]

I would have your min epap on 7 for now, I'm actually a bit aggressive with mine and have it very close to the 95%. I stop most obstructive events before they start. The 2 high pressure events are working on obstructive events, are you chin tucking or something? The other 2 is at the start of sleep, dealing with the sleep wake junk and your breathing that it thinks is an event. If you find the ASV going too high as you go to sleep blow hard to reset it. There is a bit of mask leak to fix.
Also you could bring in the minute vent and tidal volume charts, to get other data. The snore, flow limit may not be needed.

ASV is a shock to the system, it is totally different to cpap or bipap. If you can stand it but don't like it. I'd leave the PS where it is for a week. Try and resolve if it is positional, why you are obstructing.

@spy, the AHI chart can lead you to a false sense of security. It won't show the CA because everyone of them are getting treated, it's how effectively they are being treated. You are breathing all night now, so you would be feeling better even if the algorithm is choked back.

[LarryRapp]

Ajack, I'll move EPAP min from 5 to 7.

I don't think I am doing any chin tucking but the mask is still relatively new and I am not used to it.  My thought is to leave it for a while so I can get used to it. (Mask is FFM ResMed with foam. PA 20?)

I'm not sure what you mean when you say: "If you find the ASV going too high as you go to sleep blow hard to reset it."  I'm also unclear when you say: "Also you could bring in the minute vent and tidal volume charts, to get other data. The snore, flow limit may not be needed."  Do you want me to eliminate those two charts?  Thanks!

[SarcasticDave94]

...
I'm not sure what you mean when you say: "If you find the ASV going too high as you go to sleep blow hard to reset it."  ... [/font][/size][/color]

Hi Larry,

As an ASV user myself, at least for me, at times my ASV would decipher pauses in breathing while I am awake but drifiting into sleep as central apnea events and try to force ventilate. This is what a ventilator does. For me though, it disturbs my process of falling asleep. How to get the ASV to stop that and fall in line? I can do this by literally blowing back forcefully into my full face mask. The ASV stops attempting to ventilate, and falls back to the EPAP setting.

[ajack]

As you are going to sleep, you may find that the machine will initiate an unwanted higher pressure. If you exhale hard, this will reset the machine and stop that cycle of breath pressure rises. The machine is picking up awake breathing and also a probable normal reduction in MV as you are going off to sleep as something it needs to fix. You will find that you naturally settle your breathing, so as not to trigger the machine as much, while you go to sleep.

When the AHI are sorted. I find the minute vent and tidal volume chart a big help, in pointing out areas where they dip low or confirming it's working well. I try to have my min tidal volume event not less than 350-375.
The ASV follows the recent minute vent as a target. You can follow the night to see any areas when it dipped too low for too long. You can make epap/PS adjustments that normally help.

[Sleeprider]

The benefit of doing a default titration pressure experiment was we got to see you don't need high EPAP pressure. your effective range was 6 to 9. That is great news! I want to change your proposed treatment pressure to fit that range.

EPAP min 6
EPAP max 8
PS min 3
PS max 12

Please let us see this pressure range before you decide to use a higher minimum EPAP or less pressure support. I think we will narrow this down, but don't rush the process.

Who would have guessed your AHI would be less than 3 last week? This is great progress! On future charts, please move flow limits above snores as the snoring has gone away as an issue.