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.

[chrishark]

I am very appreciative of your advice and support. I am really trying to commit to the Resmed. I have been on the Philips for 5 years but have been having similar issues and thus how I ended up with the Resemed. Relaxing and breathing quietly once I have the mask and machine on is the whole crux of the problem for me because I cannot keep the machine synced with my normal breathing. I am in excellent cardiovascular health otherwise and I think that my resting respiratory rate is much lower than the machine is predicting and that seems to be what is triggering these very early ramps and my breathing is getting out of sync with the machine and causing the ramps which triggers a whole anxiety component. I have tried not to use the ramp mode because it seems to be better if I can fall asleep in normal mode. I got a little desperate last night after the first 15 minutes and turned on the ramp but could not stay asleep once it kicked off.

[SarcasticDave94]

Completely understand. Not trying to complicate or confuse your state of ASV versus SV AUTO, so my apology.

One area your old PR SV AUTO is better is that you should have a manual collection of time settings. The ResMed ASV won't, or at least my 10 series ASV didn't. ResMed has the algorithm full Auto control those. That was probably my deal breaker after 2 years of good therapy.

Look up your PR set of settings, because maybe you'll need to actually fall back to it, to get this working, and a better duration therapy. Maybe a last resort though. The PR will probably need higher pressures to work effectively I'm certain.

Plan A for now until you decide otherwise, try these 2 things, implementing at your sole discretion. Ramp, what settings are available here? If there's an auto time, try it. A setting for pressure? Try that matching your min EPAP.

Speaking of Min EPAP, trial 6 please. Then match Ramp to this too, if tolerable. This is to address Hypopnea lingering.

ASV can treat all this Apnea. Zero AHI isn't our goal though. Comfort, overnight long sessions, event control... These are the goals to chase.

ResMed Ramp once set, fires automatically every session start, including first nightly ASV power on, but also every other power on for it as well.

See what you think about this.

By the way, update us on what settings you're running since OSCAR charts can't show this yet. Thanks

[SarcasticDave94]

PS, what can you see if you edit Patient View to On, with ResMed 11 ASV?

Recap for convenience

Edit these:

EPAP 6-10

Ramp Auto pressure 6

Your EPAP barely passed 6 all session. I don't want to remove all the EPAP range, but narrow range may force ASV into PS additions sooner. EPAP felt near constant to me, while PS is short duration burst. Maybe this'll add to your comfort.

[chrishark]

Been on vacation this week so it's been a little hit or miss but I am wondering if you have any advice with regard to the air leaks. I have included two nights data. First was 9.5 hours on machine which was a record (but aided by some jet lag and an ambien). Second was the following night of about 5 hours on. I am getting quite a bit of aerophagia and it looks like quite a few air leaks. Also included a screenshot of my settings.