Poor quality sleep on ASV with good AHI

[sleepydawg99]

My sleep clinic considers me treated because my AHI is low, 0.28 in the last 6 months. However, I have been feeling worse than normal lately. I am consistently waking up periodically at night- last night I remember waking up 4 times every couple hours. I woke up feeling very tired and with a slight headache this morning. However, my machine claims I only had one event - a hypopnea around 6am.

Quick history: I've been using this machine since Jan 2021. My clinic and I have made several adjustments since I started, increasing pressure to reduce AHI and decreasing to avoid air-in-stomach. I've been using my current pressure since July 2023 and it seems to work well- no air-in-stomach and low AHI. 
Before I used this machine, I went through Cpap and Bipap therapy which did not work for me. They were not able to reduce my AHI significantly. The ASV reduced it significantly and I've been using it since.

I've reviewed my recent data in OSCAR and would now like to request some advice. Can you see anything in here that could be causing my wake ups, or anything which looks like an issue? I have been digging into the "Optimizing Therapy" wiki page but haven't come up with any ideas yet.


Thank you very much for looking!

I've attached the nightly overview for last night plus zoom views of my single event and a suspected wakeup. I had to reduce the filesize to upload these screenshots, if you prefer here is a google drive folder with the full res: https://drive.google.com/drive/folders/1...sp=sharing[url=https://drive.google.com/drive/folders/1nQKwCgjffUDstWHv5ruxizlLxJ5dqPD8?usp=sharing][/url]

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And additional screenshot

[robbob2112]

Others can chime in, but on my ASV I was having similar low AHI with frequent wakeups... After sleeprider suggested it I pinged my sleep dr and turned on ASVauto with settings to let the machine do it's thing.

If you haven't requested it get the clinician's guide from the link at the top and there is a titration section that is a good read.

That said, from my uneducated eye it sure looks like your pressures are pretty high and I would bet it is the pressure ramps that are causing you to wake up.

8.6-18 + 4-10 means you are ramping from 12.6 to 28. Doesn't look like you are ever reaching the max

If you leave your settings like they are except turn the PS to 0-10 and turn on the AutoASV your pressure floor will drop to 8.6 and only ramp if needed. Took me a couple of days to get used to autoasv, but it helped with the random wakeups.

Note - I am only 6 months in so would be good for dave or sleeprider or one of the other folks to weigh in.

[Rich66]

Agreed on switching over to ASVauto. It seems most people end up liking it. It will also give you more adjustments in the EPAP area. You'll be able to adjust EPAP Min and EPAP Max, as well as the two Pressure Supports. I'm thinking you'll end up reducing the EPAP Max and the PS Max. Also, I would lower the EPAP Min to about 4.0.

I found the ASV to be very 'trial and error' -- and the lowest AHI is not the goal. The goal is 'how do you feel'. I've had lots of 0.00 AHI and still felt miserable. If you look in the left of each persons comment, you can see what my pressures are set at -- and you can see what robbob2112 has his set at. Each person must find their own settings.

[sleepydawg99]

I appreciate the thoughtful replies!

I will try ASVAuto mode.
I'm also going to try to record my wakeup times exactly so I can associate them more easily with my data. 

Stay tuned

[SarcasticDave94]

Yes it's a good idea to change it to ASV Auto. This will make EPAP a Min/Max range. It'll very likely be more comfortable. It was much better for me than ASV mode.

In light of aerophagia, let's keep your max pressure artificially capped at 19, just 0.4 more than you're at now. If you really want identical of 18.6, it should be OK.

You'll note you can edit EPAP and PS only. It's not broke, that's what you get with the ResMed ASV. The EPAP (exhale pressure) and PS (pressure support) at the moment will equal IPAP.

How about this?
ASV Auto mode
EPAP 4-10
PS 3-9
Giving IPAP 7-19

If you do try this and feel air starved on startup, add 1 or 2 to EPAP Min.

If you want the max of 19, PS Max 9. Or if you want 18.6, Max PS 8.6.

I think that according to the OSCAR charts, whatever you have as Max IPAP it may try to go there at some point. Hence my suggested artificial Max cap.

Edit
You can juggle between EPAP and PS settings a bit to edit the delivery feel. If you use EPAP Max 10, PS 9 or EPAP 9 PS 10, the IPAP is the same. It may feel better one way vs the other.

[robbob2112]

I just remembered, before I switched to ASVauto I had aerophagia bad. We had raised my epap to a solid 9 because I was having a problem where I would have a good night and then 2 hours before waking my AHI would ramp to 25ish and stay there. So we bumped to 9 and that stopped but I started swallowing air.

So switched to asvauto and altered my settings to what is listed.... i need to update my profile as i am now on 7-9 0-5

[UnicornRider]

That said, from my uneducated eye it sure looks like your pressures are pretty high and I would bet it is the pressure ramps that are causing you to wake up.  

8.6-18 + 4-10 means you are ramping from 12.6 to 28.  Doesn't look like you are ever reaching the max

Maybe I am looking at this all wrong, rather than take what his profile read as to his therapy settings, I looked at his OSCAR Reports, as I read them his machine is set up:

                EPAP         8.6 (cmH2O)
                Max IPAP  18.6 (cmH2O)  
                PS Min      4.0  (cmH2O)
                PS Max     10.0 (cmH2O) 

Therefore his max pressure is limited to 18.6 cmH2O. which is indicated on his statistics in the left hand column.

Now if you look at the scaling of the Y-Axis of his mask pressure it tops out at 23.0 cmH2O. I noted at ~06:04:08 he has an inhalation spike that appears to peak mask pressure at ~22.6 cmH2O.  But upon closer inspection I believe there was a "Pressure Pulse" thrown at that same time as an inhalation to effectively overrun the 18.6 CmH2O limit. "Pressure Pulse" may not be the correct terminology, But I see similar Pulses at ~06:04:14, ~06:04:16  again at ~ 06:06:50, ~06:06:58, ~06:07:00. 

 But overall his mask pressure does appear to be limited at 18.6 cmH2o

I am totally new to this ASV, please enlighten me if I error.

Thanks.

[SarcasticDave94]

Yep you have it right. The ASV in ASV mode is a single EPAP, like old school straight CPAP. PS is always a range, within ResMed ASV.

The exception here would be if someone is using CPAP mode on the ASV machine. Then PS is removed leaving straight EPAP only. Within that CPAP mode, you'd be single static pressure, no variables.

[robbob2112]

I see from looking at the graphs instead of the signature - epap 8.6, ps 4-10

So it is 12.6~18.6 limited.  Which seems high to me...

and SD comment about suggested settings make perfect sense -- 7~19 covers the range the sleepdawg99 is using now, but allows for the asvauto algorithm to work its magic.

How about this?
ASV Auto mode
EPAP 4-10
PS 3-9
Giving IPAP 7-19



Thinking out loud from here on - 
And I know we are different but that lines up pretty well with what mine is - 7-19.4 --- and on my graphs I seldom pass 13 but am allowed to.  My floor is a series of waves from 7~9 typically.  So I have 7~13 in reality and am getting scores typically below 0.5 and generally feel good when I wake up.

[sleepydawg99]

Thanks all very much for your replies and discussion, I really appreciate the help. After I made this post last year I came down with a 103.5 degree fever and was sick for a couple weeks. I totally forgot about this thread.

To recap- My issue is that I'm feeling like crap upon waking up, feeling slight headache some mornings, waking up ~3 times per night despite my machine not registering many events. I stuck with the same settings until yesterday, when I made the changes you all suggested. Here's what changed:


Previous Settings:
Mode: ASV
EPAP 9.6
PS 0-10.4


New Settings:
Mode: ASV Auto
EPAP 4-10
PS 3-9
Giving IPAP 7-19

I've attached screenshots of the night before(previous settings) and last night(new settings), and two detail views of some of the events from last night. Qualitatively, I feel better this morning than yesterday morning and I only remember waking up once vs three times the previous night. I feel like this is improvement. My plan is to stay with these settings for a week to collect more data. 

Do you all see anything interesting in my waveforms that would help determine what's causing the arousals? Any suggestions on what to try next?



Google drive containing my screenshots from this thread: https://drive.google.com/drive/folders/1...sp=sharing