Covid Induced CA (Potentially) + UARS, Looking for Help with ASV Settings

[zfaulk]

Hi everyone!

My UARS journey has been quite the interesting one so I figured I'd share as well as ask for some guidance with ASV settings.

I've been dealing with UARS for a while now, and over the past year have tried treating it with CPAP, APAP, a septoplasty + turbinate reduction, & BiPAP. After dealing with flow limits all night, remaining excessively tired daily, and learning as much as I could, I started to make some progress with the help of Jason from AXG Sleep Diagnostics (Lanky Lefty). 

He helped me dial in my settings as well as identify major mouth leaks during REM sleep (I was using a nasal mask and switched to an F20 AirTouch). Here's a night's sleep at that point:

   

Then all of a sudden on November 20, 2022, I tested positive for Covid after feeling sick for a few days. Here's what that night's sleep looked like:

   

I had never dealt with more than 2-3 CA events per night prior to this. This continued daily and was resistant to settings changes, lowering pressure, etc. Obviously correlation doesn't equal causation, but it's quite bizarre that the day I test positive for Covid I have non stop CA's out of the blue. These CAs persist to this day. The only thing that addressed it was switching to ASV mode (I hacked my AirSense 10 to unlock all therapy modes so thankfully I can switch between CPAP/APAP/BiPAP/ASV easily). Every week I'll go on BiPAP for a bit to see if they're still happening, here's last nights graph:

   

You'll see some CA's while I'm on BiPAP in the beginning of the night, then I wake up from them and switch to ASV. No events for the rest of the night. Settings are:

ASVAuto
Min EPAP: 10
Max EPAP: 15
Min PS: 6
Max PS: 15


I'm still finding that I'm quite tired and am not really feeling rested. For the experienced ASV users/experts out there, is this what a "good" night's sleep with ASV looks like? Maybe I should just give it time? Any insight you can offer would be much appreciated.

Thanks!

[Sleeprider]

I'm not a big fan of using ASV for treatment of flow limitation (AKA UARS). Your original results with the were just fine, but it's a bit hard to know what the settings were with an Airbreak machine. It looks like a Vauto with PS 5 over EPAP 16. Your EPAP min is ridiculously high for using ASV mode, and it's pretty obvious that the Airbreak interpretation of ASV was not working in November when you had the really high AHI and a persistent PS of 10. The January 10 results look better, but let's be honest, you are using a modified machine that is not delivering an intended Resmed therapy algorithm. Get a true Vauto, or switch to that mode, and I can assure you that better results are possible.

[zfaulk]

Hi there!

Thanks for the response.

So just to clarify a few things: 

1. The first two images were BiPAP (VAuto). First image is 21/16, second is 20/10. The third is ASV with the listed settings in my original post.

2. The central apneas emerged the day I tested positive for Covid and have persisted since then (unless I'm on ASV of course). When I'm on BiPAP, I have those central events so I've just been on ASV as I feel absolutely terrible after waking up from a night with an AHI that high. ASV properly eliminates the central events.

3. As far as I'm aware, there aren't any differences therapy-wise for an AirBreak machine vs a true VAuto or ASV. I technically have the same firmware and algorithms as either of those machines!

4. I selected the EPAP min (10) based on that fact that it looks like I have the best results at 20/10, I'm just unable to use BiPAP with these centrals so I set up the ASV as close as I could to 20/10. Definitely open to adjustment there, but here's what a night looks like with a lower EPAP (default ASV Settings):

   


So given that my options are CPAP/APAP/BiPAP with a AHI of 50+ mostly consisting of central apneas or ASV with 0 events, I think for now I'm forced to stick to the ASV. 

I guess my main question is: looking at the ASV graph (third pic), is there room for improvement there or is that what an ASV graph of someone who is being properly treated looks like? I'm hoping there's room for improvement as I'm still extremely tired.

Thanks!

[Gideon]

I strongly suspect that you may be over titrated in your original pre-Covid chart.  You are above the standard PS with an extremely high EPAP.

Your post COVID VAuto Mode is using a virtually unheard of PS of 10.  I must ask what the rest of your settings are, the ones that most people don't touch.  Did you verify they were in default settings? Or did you change them, if so why and to what?

Regarding the ASV settings I'd suggest you reset all settings to default then repost with the results.
Please be sure to post what all the settings are.

And obviously none of these airbreak implementations 100% match what ResMed does for these machines because if it did then OSCAR would see these key settings and display them.
Airbreak was a proof of concept, not a final flawless implementation.

[zfaulk]

So the way I arrived at those settings was through titration over a period of a few weeks. A PS of 5+ with EPAP at 10+ eliminated both my flow limits and Apnea/Hypopnea events. Regardless, I'm unable to use those settings now due to the CAs. They happen even at the lowest pressure settings unfortunately, seems like it's covid induced as strange as that is.

Basically my AHI has always been low while I have a large number of RERAs/arousals (classic UARS). I went up in pressure to try to address the flow limits. Here is the progression:

This is fixed 18cm H20:

   

Note flow limits all night.

This is 18cm with EPR 3:

   

And BiPAP at 20/15:

   

There were of course many, many more settings tried in there but it seemed that IPAP of ~20 with a PS of at least 5 worked well to address the flow limits. This is of course before getting covid. Post covid I tried ASV on the default settings as well as ASV settings recommended by Sleeprider in another post. Those settings being:

EPAP Min: 5
EPAP Max: 15
PS Min: 3
PS Max: 15

---

Here's what ASV looked like on those settings:

   

To me, I feel like I look more regular on my current ASV settings listed above but definitely curious what you guys think!

[zfaulk]

Also what do you mean by the settings that people don't touch? I only have changed the settings available for each mode.

[Gideon]

Trigger can have a rather profound effect on CAs therefore knowing it's setting is important.

[Sleeprider]

I don't think the Airbreak hack allows for trigger setting in Vauto mode. Just for the heck of it, let's see you do a night with EPAP min 9.0, IPAP max 18.0, PS 4.0. Use trigger sensitivity at high if available. We can learn where you are at by seeing some more conventional VPAP settings.

[zfaulk]

This is true, I'm unable to adjust trigger on my machine.

I'll give it a shot for a few hours, but I'm almost positive I'll have centrals all night! I'll report back. Thanks

[zfaulk]

I have to say, I'm very pleasantly surprised. Is it possible that the CA's were just due to incorrect VAuto settings? Thanks so much for the advice.

Data seems to look much better with the settings you recommended:

   


Here is a zoomed in view of my waveform:

   

I still am seeing some flat tops in the second image and overall "choppiness" in the first. Does this look good to you guys or still move room for improvement?

Thanks again, really appreciate it.