HELP needed titrating ASVauto (UARS)

[Dutchie]

Hi guys and girls,

I have been reading the tips on how to treat my UARS properly and I need your help.

Not too long ago the ENT doc performed a DISE/sleep endoscopy and saw a multilevel collapse he recommended me to treat with a machine or a mandibular device. I have been using the Aircurve 10 CS-A TJ in conjunction with the mandibular device and even though I am half-functioning, I haven't had a noticeable 'good day' of late.

As I understand treating UARS I should take incremental changes to see how it makes me feel, but I have the impression I don't have a solid ASV setting to start from and would appreciate your feedback on my attached charts.

Here's a screenshots of 2 random nights from last week. I feel like absolute garbage (muscle soreness/cramps/twitching, ice cold fingers, dizziness when getting up from the couch and fatique).
https://imgur.com/a/JSCmDEJ
https://imgur.com/a/EXjr2Ck


(sorry, as a newbie I cannot enter these as a working link)

I am leaning towards using a soft cervical collar and switching to ASV auto with EPAP of 8 or 9 and a PS between 3-8. Then again, it gives the machine a free reign and I am wondering if that range would be helpful. It might just be that I need a narrower range of EPAP/PS.

What do you think? Anything that is major flag?

Thank you and cheers

[Sleeprider]

I took the liberty of fixing your links. In ASV mode with the Aircurve 10 CS Pacewave, you have zero events and no appreciable flow limitation. EPAP pressure appears to be fixed rather than auto and the PS range of 4 to 6 is something the Aircurve 10 ASV will not produce because it requires a range of at least 5 cm between minimum and maximum PS. For someone that does not need the ASV backup rate to maintain respiration rate, this seems to be working well, but it appears you could do equally well on something like the Aircurve 10 Vauto. Your charts seem to show a normal respiration rate and volume and the machine response is constrained to a very narrow range. The results with the PS range at 3.6-4.8 seems to result in a smoother respiratory flow, and is part of the reason we might want to look at a fixed PS of 4.0.

I'm not completely familiar with the settings you can use on that machine, and would prefer to see charts with the mask pressure rather than the pressure graph so we can see the breath by breath support. To learn more about your machine I hope you can answer some questions. Is it possible to set PS min and PS max equal. Are there settings for trigger or cycle sensitivity. Is the respiration rate or volume targets settable or automatic?

[Dutchie]

I was kind of hoping you would reply to my post Sleeprider

Last week I actually did set the pressure setting to epap 9 and PSmin and PSmax to 4 and I either threw off my mask in my sleep or woke up and consciously decided to sleep without:

https://imgur.com/a/9e6V6f3

Interestingly, the couple of times I used the ASV auto mode with fixed EPAP 9 and PS 3-8 the Oscar graph looked quite smooth:

https://imgur.com/a/O35Vwpv

Based on this single night I am wondering if I should use this PS range of 5 and actually titrate the EPAP backwards in increments of 0.2CM.

Thanks Sleeprider!

[Dutchie]

I was kind of hoping you would reply to my post Sleeprider

Last week I actually did set the pressure setting to epap 9 and PSmin and PSmax to 4 and I either threw off my mask in my sleep or woke up and consciously decided to sleep without:

https://imgur.com/a/9e6V6f3

I have tried this approach of an equal PSmin and PSmax  (mimicking a BiPap) in the past as well and for some odd reason the pressure very slowly decreases for some odd reason:

https://imgur.com/a/sTF5Lv2

Is my machine perhaps broken? I have never tried a BiPap machine so far as the insurance here in the Netherlands does not cover it due to my non-existent AHI. Plus I have read that ASV's are the golden standard for treating breathing events, so I managed to find my machine second hand.

Interestingly, the couple of times I used the ASV auto mode with fixed EPAP 9 and PS 3-8 the Oscar graph looked quite smooth:

https://imgur.com/a/O35Vwpv

Based on this single night I am wondering if I should use this PS range of 5 and actually titrate the EPAP backwards in icrements of 0.2CM. 

Thanks Sleeprider!

[Sleeprider]

With the ASV operating under a range of pressures, it is able to do the job it is intended for to maintain the vent rate, even when flow restriction or lack of respiratory effort occur. The range of 3-8 looks pretty good. I would be more concerned about what feels best rather than how the graphs look, but those often go hand-in-hand, so if ASV auto is working with a range of PS 5 that seems like a good idea. The main purpose of ASVauto mode is to allow the EPAP to move and to enable lower EPAP levels, so you might try EPAP 3-6 with PS 3-8 and see if that feels like a keeper or not.

Bilevel vs ASV varies by the individual. Normally the bilevel provides a nice consistent pressure support which is a smooth therapy with minimal disruption. ASV is often not tolerated due to the different pressure support over a short period of time which results in the user feeling more disrupted or tired. As I said, that is a very individual response, and you seem to be doing fine, but I rarely point to the ASV as a preferred therapy for people that are self-treating UARS because most people don't need varying pressure support to maintain inspiratory volume.

[Dutchie]

Thank you for that info. I did try out the ASVauto mode and I feel like I got hit by the all-to-familiar truck.

https://imgur.com/a/iAISLCN (sorry, the website still doesn't allow to post links)

Looking at both images it seems that at a high Ipap, my airways block, resulting in the machine flagging a FL. No expert here, but it seems that the flow rate over the course of the entire night is all over the place. Since the AHI was 0 last night, I left out that graph, and included the mask pressure and general pressure graphs.

Based on the fact that I really haven't felt significantly better on ASV, despite trying different ranges of pressure, I'm considering to try BiPap, or deduce that my breathing doesn't tolerate changing/high pressures.

Can you have a look at the data and recommend an iPap and Epap for me to try tonight?

Thanks!

[Sleeprider]

Your member level has advanced and links won't be a problem in future posts.

Keeping disruption to a minimum and improving sleep and comfort is the priority, so setup accordingly. You are treating what may be a minor problem post-surgery with a bulldozer when you just need a gentle push, so fortunately it appears your device is capable of doing that. Comfortable baseline pressure and effective but limited PS seem to be what you need. Your trial in ASVauto mode did not result in noticeable fluctuation of EPAP pressure. The setting of 7.6 only resulted in a 95% pressure of 8.0, so I don't see EPAP as being the issue here, but it also tells us that there is little or no obstruction in your breathing. You have the option to choose lower or higher EPAP pressure without much impact on your respiration. I think the source of your "truck" was the wider variation of PS. I think you should consider finding what narrow range works best for you. If you can set minimum and maximum PS to the same value, you will have replicated other Aircurve bilevel machine, which (I've already said) would have been just fine for you. Start with PS 3.0 and gently titrate upward to see where you feel best.

[Dutchie]

Well, an Epap of 8 with an Ipap of 3 isn't the magic wand. The data confirms my headache and muscle soreness that breathing was quite an effort with flow limitations at a frequent interval. The flow rate shrinks towards the end of the night in image 2:

https://imgur.com/a/8Si2Bxg


Going through my Oscar data I saw that fairly recently I tried a 4cm PS at an Ipap of and it wasn't a refreshing sleep.

https://imgur.com/a/r46pKY8

I'm inclined to set the machine to an Epap of 8 with an Ipap between 4 and 5. The extra cm might just do the trick when needed, without being too uncomfortable.

Thanks for your time and effort Sleeprider, it's so much appreciated!

[Sleeprider]

Sounds like a good plan. Keep trying, then stick with what works.