Still Exhausted on ASV

[FancyFrog]

Hi there,

I'm on ASV for complex sleep apnea and am still exhausted all the time. I feel like I've done everything, but would love some insight from all of you experts here.

I think one of the issues is just the fact that the machine goes up to such high pressures and I have trouble controlling leaks. I have to tighten the mask down pretty tight and then it gets uncomfortable. I've tried many masks and liners but still hate the one I'm using (ultra mirage with strategically placed band-aids).

I'll try to attach an OSCAR screenshot, hope it comes through.

Thank you so much!

   

[SarcasticDave94]

While there's a moderate level leaking, the making it tight to control them is very likely the issue. This indicates the mask cushion or the mask model itself is not your best answer. Have you tried other cushion sizes? Other masks?

On the settings, many Hypopnea that are looking to me to have a Positional Apnea pattern, this seems to be the big issue. Review your pillow, using several or placing yourself in position to chin tuck? If so, you're causing the chin tuck. Correct it by a thinner pillow or prevent chin tuck physically.

Fix that and you won't need too high EPAP settings. Your PS, as well, might need to go back to default 3-15. Also maybe do a new self Titration with this ResMed chart.

You can tell there's something not addressed by these high pressures, as the pressure chart is pegged to the top at Max ASV output of 25. It wants to go higher to help, it can't and it won't fix the airway external kink I believe is there with Positional Apnea.

Here's the ResMed AirCurve 10 ASV Titration guide. Read my signature links on mask primer and Positional Apnea.

   

[Dormeo]

Dave, I have zero ASV knowledge, so I wonder whether you can comment on several things. One is the amount of snoring the OP is doing, and the other is the high median tidal volume and low median respiration rate.

[SarcasticDave94]

I'm not very good yet, surprise, on the ventilation aspects. However the tidal volume does seem high, as is respiration rate being low. That RR is almost like what I'd expect in myself, basing it on my trial of the ST-A the other year. There I had to set the backup rate to 10 to keep it out of the way, otherwise it kicked in unnecessarily.

I have COPD, not indicating the OP does.

I suspect in part this maybe is linked to the possible Positional Apnea pattern, and what I'm seeing is hindered pressure settings.

[Jay51]

Great points so far Dave and Dormeo.  I have used many ventilators.  I agree that an 880 median tidal volume with (it was either 7 or 8 median respiratory rate) is a rare combination using ASV.  When respiratory rate gets low, usually tidal volume gets higher.  And vice versa.  Both try to stabilize minute ventilation if they can. 


Normal respiratory rate during sleep is around 12 to 20 or so (varies more than this even).  A very generic prediction for tidal volume is a rough estimate of 500 for males and 400 for females.  And this is based on a male and female of average height.  A much taller person or a much shorter person may need to either add or subtract from these tidal volume estimates for them to be correct during sleep.  

If you can stop the H's by working on stopping positional apnea:   

• 5.3Positional Apnea                                                                                                                                                                                                       Things like lowering pillow height, side sleeping vs. back sleeping (with something supporting chin as well), and even a soft cervical collar are the usual suggestions for positional apnea.  
  Try this and hopefully all of those large numbers of H's will reduce and your respiratory rate and tidal volume will smooth out and become more normal.  
  

[Sleeprider]

FancyFrog, you need to back off PS min to 3.0. The excess minimum PS is causing you to "stack" air, meaning your lungs are over-filling and you are not fully expiring inhaled air. This leaves less room for inspiration on the next breath and results in the high hypopnea and UA events you are seeing. We know this from your very high tidal volume, low respiration rate, very long expiration time, and minute vent that is uncontrolled by ASV. Seriously, you must reduce PS min. There is a possibility, you need to address positional apnea, but let's start with the PS min reset. https://www.apneaboard.com/wiki/index.ph...onal_Apnea One other possibility is that you have COPD that inhibits your ability to exhale. Please let us know of any relevant pulmonary diagnoses.

Once you try the lower PS, please post a new chart, and included a zoomed chart of the flow rate, mask pressure, and minute vent charts at a resolution of 3-4 minutes. I need the zoom to confirm the respiration rate and volume.