Aircurve10 ASV- new machine causing reduced REM and aerophagia

[marineman2]

Hi everyone, 

I am brand new to the forum, and so happy to have found a resource like this. You guys appear to be very educated and experienced with pressure issues, and would be so grateful for some advice from the pros! I have been struggling to say the least. I recently replaced my Philips Respironics BiPAP autoSV Advanced 30 (System One 60 Series) due to the Phillips recall with the Aircurve 10 ASV. My previous Phillips settings I used for 6 years were the following: Min EPAP- 4; Max EPAP- 8; Min PS- 0 Max PS- 8.  I require very low pressures to stay compliant, also I'm only 145 lbs, and am easily disturbed by the higher pressures as it tends to knock me out of REM sleep very easily. 

When I first received the Aircurve 10 ASV, the machine felt all over the place and I struggled with breathing rhythm most the night. I felt like it was forcing air between breaths and I was just swallowing a lot of air and ended up with aerophagia almost all the next day. I am wondering if maybe the new machine simply trying to learn my breathing rhythm. My initial settings were as follows: Min EPAP 5.0 Max IPAP 13.0 PS 0.0-5.0 (cmH2O).  After tossing and turning the first few nights with the new AirCurve machine, I panicked and called the sleep doc and they changed my settings to basically what there were on my old machine as follows: Min EPAP- 4; Max EPAP- 8; Min PS- 0 Max PS- 8. 

Here is my main problem with the new machine- 1) The same pressures used on my new Aircurve vs. Phillips just do not feel the same. Like at all. It seems like the algos are much more intense on the Aircurve or something?? Once I start to go into REM sleep the pressures feel much more aggressive and my deep sleep is completely wrecked along with persistent aerophagia. My question for you all is do you think I should go back to the initial settings of reduced pressure at Min EPAP 5.0 Max IPAP 13.0 PS 0.0-5.0 (cmH2O) and just give it time to let the ASV machine get used to my breathing patterns?  My AHI was also much lower at these settings. Here are my charts and would really love any feedback. 

My #1 goal is I just want to be able to have lowest pressure possible with least disturbance in REM but maintain effective therapy. Thanks!

[LindanHotAir]

If you include the mask pressure trace it will show more of what the machine is doing. The Resmed bases its  backup rate on your recent breathing patterns, with a default rate of 15.   The Philips has a programmable fixed respiration backup rate. I tried the auto mode on the Philips and it was not at all comfortable for me, so I use a programmed rate of 9. From what I have seen on other charts the mask pressure wave shapes are different between the machines. Others with experience with the Resmed can provide some useful guidance.

[Sleeprider]

The Aircurve ASV averages the minute vent over fewer breaths and less time than the Philips and can respond faster to reductions in minute vent than the Philips. We often see a Philips machine take 4 breath cycles to go from minimum to maximum PS, while the Resmed can hit that maximum practically on a breath by breath basis. I think to help you, we may want to look at your flow rate in a much closer zoom that shows 3-minutes of therapy at a time with the shape of the respiratory flow rate, mask pressure and I'm tempted to look at minute vent as well since that is the target.

Looking at the two graphs you posted, the median and 95% pressures are quite similar in spite of the higher EPAP on November 9. The maximum pressure on November 26 is considerably higher and these excursions above 13 cm may explain the increased aerophagia. The inspiratory/expiratory times caught my eye and you have a relatively short expiration time to inspiration time. It may be that the ASV is not giving you enough expiration time, and this leads to some breath-stacking. Unfortuanately, we don't have a trigger sensitivity or minimum/maximum time of inspiration to work with on this machine. It would be very interesting to look at your Philips results in comparison, because pressure is delivered as more of a square wave, and this usually results in more expiration time. My impression on settings is of course to use what is most comfortable. You should limit max IPAP to 13 but use the higher minimum IPAP since your results seem to be better with IPAP 5.0 to 8.0 and PS 0-5, and this may reduce the aerophagia. Have you ever tried PS min of 1 or 2? This sometimes can reduce disruption by providing more consistent pressure support. I'm surprised at how well the machine mitigates central apnea with a PS max of 5.0.

[SarcasticDave94]

It is odd that treatment is showing good with low and intentional limited pressure set, but it's what it is. I am wondering myself if the quick response and lack of time controls is a stark contrast and possibly the source of therapy and aerophagia being a bit disrupted for the time being.

If you have them, post a sample of your old Philips up in a post.

[marineman2]

Thanks so much for the replies guys. I am in desperation mode. I am tempted to go back to the Phillips but the machine is 7 years old and fear I am stuck with adopting new technology. I am not too concerned about the recall since I never used the SoClean cleaning device. I really just thought it would be better to just go ahead and replace it with the latest tech. Now I am not sure. I just want my sleep back! Here is the latest from my Phillips machine. These are 3 screenshots from the same date. Sorry I wanted to show you screenshots of all the data.

[marineman2]

Thanks for the reply. Here is the data showing mask pressure for 11/26

[marineman2]

The Aircurve ASV averages the minute vent over fewer breaths and less time than the Philips and can respond faster to reductions in minute vent than the Philips.  We often see a Philips machine take 4 breath cycles to go from minimum to maximum PS, while the Resmed can hit that maximum practically on a breath by breath basis.  I think to help you, we may want to look at your flow rate in a much closer zoom that shows 3-minutes of therapy at a time with the shape of the respiratory flow rate, mask pressure and I'm tempted to look at minute vent as well since that is the target.  

Looking at the two graphs you posted, the median and 95% pressures are quite similar in spite of the higher EPAP on November 9. The maximum pressure on November 26 is considerably higher and these excursions above 13 cm may explain the increased aerophagia.  The inspiratory/expiratory times caught my eye and you have a relatively short expiration time to inspiration time. It may be that the ASV is not giving you enough expiration time, and this leads to some breath-stacking. Unfortuanately, we don't have a trigger sensitivity or minimum/maximum time of inspiration to work with on this machine.  It would be very interesting to look at your Philips results in comparison, because pressure is delivered as more of a square wave, and this usually results in more expiration time.   My impression on settings is of course to use what is most comfortable. You should limit max IPAP to 13 but use the higher minimum IPAP since your results seem to be better with IPAP 5.0 to 8.0 and PS 0-5, and this may reduce the aerophagia.  Have you ever tried PS min of 1 or 2? This sometimes can reduce disruption by providing more consistent pressure support. I'm surprised at how well the machine mitigates central apnea with a PS max of 5.0.

Hey Sleeprider, I posted the data from my old Phillips machine in the comments. FYI- The side effects I am experiencing during the day (tingling limbs, abnormal breathing, slight confusion) all point to elevated C02 levels from not exhaling all night.

[SarcasticDave94]

Post up one more chart of your old Philips or tell us the same info. Myself, I am looking for 2 things. All machine settings and I/E timing info.

It may be not too significant, but note that you ran Flex 3 on this Philips. It just showed in a few charts. That has been an issue with some others in its own right with other PR machines. If nothing else, this deletion of Flex like action will enhance feeling differences in the ResMed.

PS me wonders if the OP will become another ResMed ASV lack of timing control victim.

[marineman2]

Post up one more chart of your old Philips or tell us the same info. Myself, I am looking for 2 things. All machine settings and I/E timing info.

It may be not too significant, but note that you ran Flex 3 on this Philips. It just showed in a few charts. That has been an issue with some others in its own right with other PR machines. If nothing else, this deletion of Flex like action will enhance feeling differences in the ResMed.

PS me wonders if the OP will become another ResMed ASV lack of timing control victim.

Yea, sorry the data isn't importing correctly to OSCAR. I keep getting an error message saying OSCAR does not recognize some of the settings for this device and wants me to send a zip file to their support team. I wonder if its because its an older device?  Anyway, you guys are spot on. I believe I am a victim of timing control here. I had the same initial problems with my Phillips ASV and it wasn't until I used the Flex relief setting and pressure control by my sleep doctor that I found relief of horrible CO2 buildup symptoms- (tingling in hands and feet, shortness of breath, confusion and difficulty concentrating the next day, etc).  This all makes sense that I am having high CO2 symptoms as a result of using the Aircurve 10 ASV with no timing adjustments. Well, thank goodness for Youtube, I went ahead and removed the foam dampener culprit for the mass recall and I will continue to use the Phillips.  I may even try to find two or three more machines I can buy so I never run into this problem again.  I need my life back! Thanks so much for your help, I would have gotten the runaround by my sleep doctor and DME. I will make sure to donate to the forum

[Sleeprider]

Your chart for the Philips therapy does not show the pressure. The statistics suggest a median 7/5 pressure and 95% at 10.13/6.25 which is only PS 4. I just want to confirm you have central or complex apnea, because in theory, these pressures would not normally correct CA.