Desperate for some help with ASV for CA

[chrishark]

I have had idiopathic central sleep apnea my whole life. I was only diagnose formally about 6 years ago after a severe apneic event that led to an ER visit. I had an AHI of around 30 on my initial sleep study of which 90% was central with about a 10% component of OSA. I failed the CPAP on the split night study so they put me on BIPAP and after one horrible night where my central events worsened and a second in house sleep study later, was put on a Philips ASV. I have been on that for nearly 6 years. I have been through all of the typical struggles with masks and such. I settled on the creamware nasal mask and I use hostage tape to tape my mouth shut. I have always struggled with the initial period of falling asleep with the machine and that struggle has worsened significantly over the past 6 months.
My issues are: 
1. that my machine starts ramping on me before I am even asleep.
2. If I am exhausted an able to fall asleep with it, I think I go really quickly into central events and the machine ramps hard and that startles me awake and creates anxiety. 
I have had my Philips machine for nearly 5 years (screenshot of typical recent night on the Philips attached) and thought maybe the last 6 months were a deterioration with the machine. So I scheduled an appointment and got a Resmed Aircurve 11 prescribed. My first few nights were the same exact problem with the machine ramping before I was even asleep. I then miraculously had one great night of sleep on the Resmed (screenshot attached) but have not been able to replicate it. 
The machine ramping before I am asleep is driving me nuts and no matter how tired I am, I cannot fall asleep with it. Last night was particularly bad and was pressurizing so much it was filling my mouth with air. (screenshot attached). I am a 48 yo male 6'3", 195 lbs.
I am losing hope and desperate for help of which I have received none from my sleep provider (a PA) nor my DME supplier.

[SarcasticDave94]

OK we're going to help, but we need to do the OSCAR charts again, including the left panel minus calendar. If your OSCAR is a recent version, this should be simply an F12 screenshot. After turning calendar off that is.

Prep us some please. You use ResMed ASV or another? What are the therapy settings? I can't see those yet.

[chrishark]

Thank you so much. I have done those screenshots. Historically I have been on a Philips respironics and I still have that machine. I have intermittently been using that for the past couple of weeks. I have a new Resmed Aircurve 11. I have redone the screenshots from that one good night I had on the Resmed and a typical hour of another night where I can't fall asleep. And I have included a night from the Philips too. 
The Resmed is set to EPAP 5-15 and Pressure of 12. The Philips has the same EPAP but a higher PMax of 17.

[SarcasticDave94]

Alright, this helps. I'll suggest a few things, starting with let's focus using the ResMed for now. I've had the 10 series ASV and would have done excellent except I also have COPD.

OK back to your therapy. On the ResMed, try the following changes:

Mode ASV Auto
EPAP 5-15
PS 3-15
This is near default otherwise.

This will get you 8-30 IPAP, although the IPAP will max at 25 due to physical ASV limits.

Try that a night, note how it went, and include an OSCAR chart that has these:
Events
Flow Rate
Pressure
Leaks

Skip Flow Limit, the ASV algorithm will have a busy looking FL chart, no issue it's an artifact of CA therapy and the ASV doing its thing

[chrishark]

Thank you for the recommedations. I did that last night. I still did not make it past the first hour as I struggled to fall asleep and then woke pretty quickly due to the pressure. Attached is the screenshot with those parameters you suggested.

[SarcasticDave94]

OK, it's a start. Think about when you start ASV therapy at night. Delay actually turning on the ASV a minute or so, probably the masking up as well, in order to settle your breath rate. Settle into bed, moving blankets, pillows. Then try ASV

If you mask up with higher breath rates, the ASV attempts to pace this, setting you up for higher rates than normal.

A question to consider, is it high pressure that hindered or that it's too low?

PS note your charts Philips vs ResMed

Your PR didn't pass 11 or so pressure, likely due to the Philips Respironics reactionary action. The ResMed responds faster, anticipating events, getting higher to actively combat the issue. The PR reacts too slowly to address some events.