ASV Mode vs ASVAuto Mode - What's the Difference?

[slowriter]

First, you should start your own thread.

- is AutoEPAP the only feature of the ASVAuto mode ?
- is AutoEPAP only used to deal with the obstructive SA?
 From the brochure, the device will by default stay at the min EPAP and will only increae when OSA event is detected, and when the OSA event is gone, it will return to the min EPAP. Is that how it works ?
- is the dynamic IPAP (i.e. PS) used to treat the CSA ?  

- Does AirCurve 10 ASV match the pattern in realtime based on data from each session, disregarding the previous sessions ?

Yes, to the first three questions, though I think the dynamic algorithm also probably has other benefits. It's basically aiming at normalizing the airflow curve, which is why it's sometimes used off-label for things like UARS.

Your last question: my understanding is yes; that it only looks at the preceding few minutes.

[Sleeprider]

ASVauto will increase EPAP when conditions are detected that indicate obstruction, and mainly for events like hypopnea and UA which are assumed to be obstructive if they do not respond to the ASV pressure support.  Generally, we learn more by observing the changes of pressure in ASVauto mode, however most ASV prescriptions are written for a single pressure in ASV mode.  The ASV auto capability is a relatively new innovation in this therapy, and many doctors either don't understand it or are unaware of it. I have never seen a machine "out of control" with ASVauto.  That said, individuals can usually expect good results with standard ASV mode, provided there is no need for occasionally higher EPAP.  The standard starting pressure recommended by Resmed for ASV mode is EPAP 5.0, PS 3-15 which yields your maximum pressure of 20.  In ASVauto mode, Resmed recommends EPAP min 4.0, EPAP max 15.0 and PS 3.0 - 15.0. So your doctor is just going by the book for ASV mode and there is nothing special about your script. On the forum, we nearly always coach new users in ASVsuto mode, especially if there has not been a prior titration.

[struts]

Thank you for the advice.

- In my case during trial, with EPAP fixed at 5cmH2O, PS 3-15 with max IPAP at 20, 
I assume the default setting of ASVAuto mode, EPAP 4-15, PS 3-15 should probably give me a result as good as the trial setting and may be even better overall benefits , right ?

- Do I need to set the max IPAP at 20, as with the ASVAuto default setting, the max IPAP can be as high as 30cmH2O ?

- It seems to me that with the ASVAuto mode, the titration is not needed, as the ASVAuto mode technically does the job of tritration, unless the sleep apnea condition cannot be solved within the range specified, right ?

- Do I need to turn on the Ramp which is by default OFF  ? I wonder why it is turned off by default.
- Any other setting i need to pay attention to ?
- Are these setting the default value ?
  Climate Control : Manual 
  Humidifier Status : On
  Humidity Level : 5
  Ramp  : Off
  Smart Start : On
  Temperature : 27C
  Temperature Enable : 2

Thanks.

[Sleeprider]

In ASVauto mode the only settings are EPAP min and max and PS min and max. The potential highest pressure is the sum of EPAP max and PS max, however if that exceeds 25 cm, the machine will increase EPAP if needed above 10 cm and that will reduce the maximum PS available. ASV is not effective and events are not detected during ramp. Many people experience central events at sleep onset, so it is recommended that ramp be left off unless you simply cannot tolerate the pressure settings. Keep in mind we will make some adjustments for comfort and effectiveness once we see your needs and get your feedback. The settings you are using look fine to me, but I would turn humidity down to 4 until you determine more is needed.

[RayBee]

Welcome to the forum Struts.

For me, if the pressure exceeds 17cm, I get an uncomfortable amount of air in my stomach - aerophagia.  So I have to make my adjustments so max EPAP + max PS does not exceed 17.  Also, I generally am able to fall asleep fairly easily.  But if my ASV gets too aggressive during that time, I will just fight it.  So I use the ramp for only 5 minutes which seems to cover the time when my mind unwinds and my body starts to relax.  Without the ramp, I find myself fighting the machine maybe 50% of the time as I try to fall asleep.

The bottom line is to learn about and adjust these "comfort" settings around what works for you.  The last thing you want to do is give up all together.  Some people unfortunately do, and over easily correctable problems.  And your best gage of efficacy is how you feel during the day assuming you get a restful nights sleep while in therapy.  Don't get obsessed with the ever elusive 0 AHI.  Efficacy is much more than just a number.

Stick with it.  There is much to learn about your machine, mask, settings, and how your body works with or against xPAP therapy.  It took me over a year to discover simple things, like when my AHI starts to creep up, it is an indicator that my headgear straps are stretching out a little too much.  So it's time to snug them up or replace the headgear.

The ApneaBoard is by far the best place to get help with your xPAP needs.  All the best on your journey.

[struts]

Sleeprider, RayBee,  Thank you so much for the advice.

- "In ASVauto mode the only settings are EPAP min and max and PS min and max. The potential highest pressure is the sum of EPAP max and PS max, however if that exceeds 25 cm, the machine will increase EPAP if needed above 10 cm and that will reduce the maximum PS available."
I see. The AirCurve 10 ASV can only produce max pressure of 25cmH20, so the machine will increase EPAP if needed to fix the OSA, and reduce the PS to keep max pressure under 25cmH20, right ?

- Does the ASVAuto always start and maintain the EPAP and IPAP at the min level and wil increase when event occurs, and return to the min level, after the events are gone ?

- Do you guys directly change the setting through the clinical menu ? I have the impression that the patients are not supposed to have access to the clinical menu and especially not supposed to make those pressure change.

- Raybee, your comment " your best gage of efficacy is how you feel during the day assuming you get a restful nights sleep while in therapy.  Don't get obsessed with the ever elusive 0 AHI.  Efficacy is much more than just a number."

I always thought AHI=0 is the ultimate target, how is your experience of the day time feeling and the AHI you got ?

- "I have to make my adjustments so max EPAP + max PS does not exceed 17."
Do you adjust the max EPAP or the max PS ?

- About the Smart Start setting, sometimes, I found it starting too soon while I was fitting my mask, but I found it quite handy when I took off the mask, it stopped automatically. What are your experience with Smart Start ?

[Sleeprider]

ASVauto starts at the minimum EPAP and PS, and raises EPAP for obstructive events, and uses PS to maintain the user's minute ventilation rate. If obstruction is not present, EPAP diminishes to the minimum and without central or breathing events that reduce tidal volume and minute vent, the PS can stay at the minimum. For setup purposes there must be at least 5 cm pressure difference between PS min and PS max.

We are not reluctant at all to access the settings menu and make changes to optimize therapy. We do this to minimize changes in pressure, and improve comfort, and in accordance with the recommended titration protocol by Resmed posted above. This article discusses how we view patient empowerment to manage their own therapy for their comfort and efficacy https://www.apneaboard.com/adjust-cpap-p...tup-manual We are here to help educate and guide your use of these machines, not to offer medical advise, but we have a pretty good track record. I will point out that the "practice" of titration is nothing more than a disciplined approach to problem solving using "trial and error". On the forum, we have the advantage of observing detailed results in OSCAR and getting the user's feedback on how they feel. A clinical titration is limited to a few hours of trying different pressures with "the AHI numbers" defining success. We have improved on clinical results countless times.

AHI of zero is not practical and is not normal. Our objective is to use positive pressure strategies to minimize abnormal breathing to improve comfort and sleep quality. We specifically try to keep members from obsessing over numbers, and to focus on how they feel. Having realistic expectations for therapy is important, as is realizing not all of your problems are related to your ASV or PAP therapy.

[RayBee]

- Do you guys directly change the setting through the clinical menu ? I have the impression that the patients are not supposed to have access to the clinical menu and especially not supposed to make those pressure change.
I'm 100% out of pocket and have zero support from Kaiser other than initial testing, evaluation and prescription for my ASV with basic settings. I'm now on my own with my personally purchased machine. So I tweak my settings for best results. Now I can tell a difference with a small 0.1 cm change if I need it. But as to your question, it is my understanding that there may be negative consequences with your HMO, sleep doctor, etc, if you are under their care, and you change settings in the clinical menu. Some can talk their way out of problems when the doctors find out that the patient knows what they are talking about and justifying the changes they have made (with or without mentioning the Apnea Board). Some doctors are receptive and reasonable, but some get P*ssed off when the patients know more than the doctors do.

- Raybee, your comment " your best gage of efficacy is how you feel during the day assuming you get a restful nights sleep while in therapy.  Don't get obsessed with the ever elusive 0 AHI.  Efficacy is much more than just a number."

I always thought AHI=0 is the ultimate target, how is your experience of the day time feeling and the AHI you got ?
My "raw" AHI numbers are usually between 4 and 10. My "real" AHI numbers after discounting the SWJ (Sleep Wake Junk - search the AB for more on this) is about 1 to 3. Well within normal operating parameters as Commander Data might put it. For me, it's kind of a slow rise and fall when something goes South. I can go three to four nights with no ASV therapy and only after that, my daytime energy starts to decline - along with other sleep apnea symptoms. Then another two or three days on the ASV brings my daytime energy and feeling-well back to my new ASV-normal. When I started my journey, it seemed that it took about a year for me to really realize the benefits of therapy. No fault of the machine, but attributed to my journey as a novice and eventually learning what settings worked best for me, what mask works best, and basically every detail as it relates to sleep and ASV therapy. Another lag in feeling better was probably due to the years of damage to my health in so many ways attributed to my complex apnea. It seemed to take a year for my body to heal and adjust. But I'm living the dream now as a graduating student of hose-head-ology. It was a seemingly long journey, but worth every minute. Now I am reaping the rewards of consistent and effective therapy. My recommendation would be to take the bull by the horns and never give up. Only look back to realize how far you have come and the benchmarks you achieve.

- "I have to make my adjustments so max EPAP + max PS does not exceed 17."
Do you adjust the max EPAP or the max PS ?
For me, it seemed that adjusting EPAP was dictated more by the search for best personal comfort. Too low or too high of a range resulted in an unnatural struggle to inhale or exhale. I adjusted min and max PS more as a result of my AHI numbers, clean waveforms in OSCAR, and avoiding aerophagia. I seemed to do best by finding my optimum EPAP settings and then adjust the PS secondarily. Also for comfort, I had the ramp set to "off" for a long time, but realized I could fall asleep much quicker with having it "on" and 5 minutes. And I set the pressures to eliminate any feeling of struggling while breathing. Then I am calm and that results in getting to sleep much quicker which adds to my quality of sleep and length of therapy. 

- About the Smart Start setting, sometimes, I found it starting too soon while I was fitting my mask, but I found it quite handy when I took off the mask, it stopped automatically. What are your experience with Smart Start ?
I absolutely love Smart Start. I like the way it senses my breathing and starts automatically. And I reach over and tap the power button if I need to get up in the dead of night which turns it off. That way the few seconds of a PAP hurricane doesn't wake up my wife. She says she doesn't even hear my ASV machine.

Great questions. I had teacher who once said "The only stupid question is the one that goes unasked."

[struts]

Sleeprider, RayBee, I appreciate so much your advice and personal experience which really helped me learn a lot.
After the trial and the final prescripton written by the sleep doctor, I am now on my own, i.e. not being advised by any sleep doctor. I did not do any titration test at the sleep clinic.

I did not learn much from the sleep doctor or from the store providing the trial machines.
However, I already learned 100x more just from the few advices given to me on this board so far.
You guys are just awesome.

I have to take some times to digest the information you guys provided.
More questions...

- Right out of box, with the factory setting, what is the default mode ? ASV Mode or ASVAuto mode ?
 In the above image of Protocol, are those default settings  for each mode the factory settings?

- if ASVAuto mode is not the default setting, should I ask the store to do the setting or it is better for me to do it directly, as there is not much to change, i.e. just change the mode to ASVAuto in the clinical menu ?
With the current COVID-19 pandemic, I think I should avoid the box being opened by the store staff to change the setting of the machine and risked being contaminated, or am I being unnecessarily paranoid ?

- In the above image of Protocol, for ASV Titration Protocol, it is the ASV Mode,
 and ASV Auto Protocol , it is the ASVAuto mode.
 
 In the ASV Auto Protocol, it seems to me that not much needs to be done with the ASVAuto mode, unless the UAO is not resolved when Max EPAP is reached and/or in the case of feeling claustrophobic.
 It goes back to my earlier question, with ASVAuto mode, is the titration not needed, as the ASVAuto mode technically does the job of tritration ?

 In the ASV Auto Protocol, the mask excessive leak seems to be not addressed ?

- Sleeprider wrote "On the forum, we nearly always coach new users in ASVsuto mode, especially if there has not been a prior titration."
 In my case, I did not do the titration test, only got a final prescription from the sleep doctor, who specified ASV Mode.
 Does that mean, I should try the ASVAuto mode right away.
 On the other hand, I read this article from the link you referred above.
 https://www.apneaboard.com/adjust-cpap-p...re-on-cpap  
 "We do not recommend that new CPAP users change their pressure until they have had their first sleep study and lived with the prescribed pressure settings for several weeks. "
 
 Does that mean I should start with the ASV mode first as it was the mode I was prescribed during the trial ?
 
Thanks.

[Sleeprider]

Struts, just request the setup manual for the Resmed Aircurve 10 ASV. I don’t know what the factory default settings are, but you can easily change them. I recommend you start with ASVauto mode as shown in the Resmed titration protocol. No one has titrated you and this makes the most sense. As soon as you post the first night of data and give us qualitative feedback we will jump right in wit suggestions. If no one ever told you, all PAP titration is trial and error and follow an optimization procedure we know well. You have to first jump in the pool, then we will teach you to swim. That first jump is scary, but we will be there to help.