Resmed ASV vs Dreamstation ASV

[Justanotherguy]

Hello everyone, I'm a long time reader of this forum as I've been in the sleep disordered breathing rabbit hole for a few years now but I finally felt I really had to post and ask for the communities help.

I've been messing around with my out-of-pocket paid Phillips Dreamstation ASV. I've been trying to tweak my settings for a small year now, and although things are definitely better - I am still quite tired. I've had a sleep study with barely any obstructions, about 4-5 hypoapneas per hour and 25-30 arousals per hour. The doctor sent me away with a CPAP on 6cm2 of pressure and we never spoke again... Getting to bilevel is not even possible, so I went ahead and got my own ASV.

My breathing still looks 'off' when I investigate my data in OSCAR, I've been trying different combinations of EPAP/PS/Backup rate, and nothing seems to work very well. Very very rarely I have a day where I feel kind of good. Most of the days I feel tired, but with therapy it is bare-able at least. I'm getting MMA surgery in about a year, but I want to feel normal in the meantime. I've been raising EPAP/PS to eliminate flow limitations but I'm now at the point that increasing it further just gets me a load of centrals in clusters.

I've also had a consult with dr Krakow and we went over my situation. He said that it happens that people just don't respond well to the Phillips Dreamstation ASV and I might need to switch to the Resmed Aircurve ASV. Since I pay out of pocket I would really like to get the opinions of some of the experts here. I will add the last 3 nights of data in here.

Do you think I should try/switch to the Resmed Aircurve ASV? Is it possible that works way better than the current therapy?

Interestingly the last night with the high amount of clustered centrals is one of the rare nights where I actually felt ‘quite okay’ the whole day.

[Sleeprider]

It's really difficult to advise on flow limitations when the flow rate chart is at this full-night resolution. We need to get this zoomed into a timeframe of 3-4 minutes where we can see the respiratory flow rate and machine pressure response on a breath-by-breath basis. My assumption is that you have gone too far in increasing EPAP and you will be better off focusing on comfort and a more natural respiratory volume for you. I normally suggest the Resmed Aircurve 10 Vauto as the first go-to for UARS because we can isolate a range of pressure and single pressure support that works best, and the Easybreathe™ algorithm ends up with the kind of comfort and timing that works best. Anyway, let's get get a better look at the flow wave and see where this needs to go. Also, what minimum level of EPAP pressure allows for elimination of obstructive events?

[Justanotherguy]

Thanks Sleeprider, really appreciate the support. I'm willing to get the Resmed VAuto if you think it will be better. Attached some screens of last night, I do notice that my breathing is always clustered with issues. This shows in flow limitations but also in custom flags I setup. Here we go:

I can't add more because it says - not sure what to do about this:
Please correct the following errors before continuing:

• Sorry, but you cannot attach this file because you have reached your attachment quota of 5 MB
  

[Sleeprider]

The images from 04:00 show no flow limitation. At 05:45 there is some mild flow limitation and some rough transitions from EPAP to IPAP. For the most part, your machine is staying at PS min 4.0 and you have 100% spontaneous breathing.  If the Vauto is not a huge stretch for you it will be better for several reasons.  You don't need the triggered IPAP, you don't need variable PS and you would benefit from the more refined flow shaping.  The image below shows the typical timing of a Vauto at PS 4.0, and the takeaway is that the pressure support rises with the inspiration (above the zero line) and reaches peak pressure even as inspiration is reaching zero. So it follows inspiration and continues to provide support to fight flow limitation, right up to the moment expiration begins and flow reverses, and it stays low until inspiration begins again.  Compared to the Philips algorithm, which you can see provides a very rapid rise and decrease that does not time out as well with your spontaneous effort.  You can play with your own graphs to see if this becomes more comprehensible, by moving mask pressure under flow rate and moving your cursor that sets that green vertical line so you can see what each is doing by reading the mask pressure and flow rate at the top of each respective graph.  I think this will show you that rather than following your breath, the Philips is leading, providing PS before you need it, and quitting when you need it most.  I would be interested to hear how your own observations pan out on this theory.

Notice in this graph, my poorly drafted vertical line shows flow rapidly dropping from a peak over 50 L/sec to 13.7 L/S, at which point the PS is at its peak of 16.3 cm. Only after flow reaches zero does the pressure support drop out for expiration.

[Justanotherguy]

I get exactly what you mean, and it's one of the things I noticed (I have a data science background, so I can analyse quite well). So you are saying the PS should raise until the flow reaches 0 again? I tuned the Rise time of the device, so I can easily match the patterns. My initial thought was that I needed a low rise time, because the peak pressure of the mask was always 'too late' to prevent the flow limitation. I could alter the rise time, or mess with Biflex?

PS in this screen stays at 4 because I set the PS range to 4-4, so that adds up. I've tried dozens of different combinations though, and haven't been able to figure out how to make it work. If you like I can also share screens of open PS ranges, I also have some old Airsense data with fixed epap's, ranges, including 0 to 3 EPR. If there is anything that can help to decide on whether to get the VAuto, Resmed ASV or give up altogether I'd be happy to provide it, just let me know what you need or want to see.

[Sleeprider]

The sun is shining and the breeze is blowing, so I'm off for some sailing on this Memorial Day. Will pick up later.

[Justanotherguy]

Thanks, I'll be eagerly waiting and refreshing.

[Justanotherguy]

Feeling so fatigued again, let me know if you'd like to see any more data. I attached a screenshot of last night. I decreased EPAP from 10 to 9, increased PS from 4-4 to 5-5 and increased rise time from 3 to 5. I see a lot more custom flagged events which often correlate with feeling worse. I will probably just order the VAuto tonight (its mid-day here) unless we come to another conclusion meanwhile.

[Sleeprider]

The segment at 5:32 has several flow limited breaths. The pressure support timing looks correct, but did not fully stop the flow limits. There is not an apparent arousal from this, and respiration rate remains in your normal range. The inspiration time graph is counting a lot of expiration time at null flow as is typical for these machines. While the graphs show a low event rate and overall good results, there is not clue to why sleep is unsatisfactory. In the full-night graph there are numerous spikes of flow above the normal maximum that may be arousals. You may want to look closer at those.

You expressed the concern that poor sleep and fatigue may be external to the therapy and respiration. What are your thoughts on that? What makes you think MMA is a solutions?

[Justanotherguy]

Is there anything you'd like to see zoomed in? I do notice I'm at 7.98/8 of my MB limit, do I have to remove old screenshots?

Additionally, in my sleep study I did have an AHI of around 8 - basically only hypoapneas. Besides that I had an average of 25 arousals per hour. A scan was made and my airway is small, and moving the jaw forward would give it a lot more space. I have no other indication where the fatigue could be coming from (except Asthma/Allergies, which are both very mild), and all my symptoms seem to be related to poor REM sleep (fatigue, poor memory, poor concentration, no recollection of dreaming). At least that is to my knowledge, I am basically at the point where if MMA has a chance to improve this, I will take it. I'd love to explore this with someone else, but I literally don't know where or who to go to, or what to try now. Open for any suggestions.