[Treatment] ASV settings for treatment of complex sleep apnea

[SarcasticDave94]

iVAPS is at a minimum going to be in the ResMed ST-A or the bigger NIVs Stellar and Astral. It's main use will be to combat and treat apnea events when respiratory restricted disease is present also. It could be what I consider old style CA combat.

It does seem that you're chasing a tiger. The recent charts look pretty good, yet you're chasing a shotgun approach of PLM, CA, medication, and so on as cause to some vague tiredness. It seems to me that you might be too ready to spin the dials. Any vague not resting well means dial spins. It doesn't appear where there's any time for any pressure set to stabilize. Without trying some set of pressures for more than a day, you're only adding to the possible causes list instead of eliminating anything. It appears you have lots of "could be this" rest robbers but none that are really known. Maybe focus on eliminating some causes, and realize it might be a cause that isn't Apnea related at all. You've said some non Apnea related issues were eliminated on causing lack of rest, but that indicates all non Apnea reasons weren't eliminated.

That's just my 2 cents and isn't meant to be an insult. Actually I'm trying to help by getting you to think reasonable and rational. Don't spin dials daily, and also try to eliminate causes. It may be better to eliminate current lists of causes then look at some other possible things.

[Geer1]

I looked at the data. Getting some of your previous data (at higher pressure supports) as well as some from vauto might help a bit too (to see the difference in details, compare breath waveforms etc).

Some immediate points that stand out to me.

These new settings without a doubt are reducing pressure cycling and higher pressure periods. On Mar 27th your average PS (IPAP-EPAP) was 7.6 due to extended high PS (and depressed RR), on the 28th it was 5 which was a better night. All 4 days on these new settings it has been 3-3.1 which tells me it is much more consistently relying on your spontaneous breathing which I do think will have an effect on long term as body continues to adapt.

I don't believe any of the apneas or hypopneas in these 3 days are real (maybe 1 or 2 of them). They all occur post arousal and almost for certain are you holding your breath while changing position or transitioning back to sleep.

Most of your sleep disturbances do not appear to be breathing related maybe the very odd RERA but everyone has the odd RERA. Your periods of disturbed sleep usually follow what appears to be normal breathing then there is an obvious spike etc in data (which usually happens during an arousal) then your breathing looks a little bit weird (as does arousal breathing for everyone) which is amplified by the ASV effects (trying to maintain MV) and probably the odd central apnea (due to higher PS and transitioning back to sleep).

There is some slightly odd looking breathing (more so breath waveforms etc than signs of flow restriction, apnea etc) at other times but it is impossible to determine what is going on especially with the ASV pressure cycling and backup rate muddying the data. My guess is a mixture of rem sleep (which is odd breathing for everyone), awake breathing (you mentioned trouble sleeping last night) and perhaps some periods where the machine is fighting centrals. I only saw a couple very minor spots that I thought a higher PS max might have helped with what appeared to be centrals so I think you are pretty nailed in on the settings right now.

Not sure if you take or have tried melatonin. I didn't think it helped much first time I tried it but for a while I have been using a 3 mg melatonin, 150 mg magnesium supplement before bed that I am pretty sure helps me sleep better throughout the night. Maybe it is is the melatonin, maybe the magnesium or maybe the combination but it seems like most nights I forget to take it I seem to wake up early morning whereas if I take it usually sleep all night.

I don't think Clonazepam is too much of a worry to use as a short term trial (week or two to start) unless you have a past of dependency issues, obviously would be something to discuss with your doctor. It is one of the main treatments for insomnia, restless legs, PLMD, rem sleep disorder, anxiety, list goes on and for sleep issues it is usually a low dose that works (0.5 mg sometimes 1 mg, I tried 0.5 mg for anxiety reasons a couple years ago and barely noticed any effects). My thoughts behind the Clonazepam are the wide range of effects that are well known to help sleep quality in multiple different ways, I personally haven't heard of Clonodine before.

The only reason to ever really consider IVAPS is if you have hypoventilation (inadequate spontaneous breathing) which I do not believe you have (PSG required to diagnose imo). Frankly I believe thinking it might help is grasping at straws. If anything maybe a Phillips Respironics ASV would be beneficial as my understanding is they are much less reactive than Resmed (which is the reason some people prefer Resmed but also the reason I think creates a bit of an issue for you and others like sheepless).

Let me know if you want me to point out some of these points in your data (if you don't understand some of my comments).

[sheepless]

"maybe a Phillips Respironics ASV would be beneficial as my understanding is they are much less reactive than Resmed (which is the reason some people prefer Resmed but also the reason I think creates a bit of an issue for you and others like sheepless."

I'd love to know more about this. I asked a while ago but didn't get a response. idk anything about algorithms and whether the following makes sense but since PR machines apparently respond to snores rather than flow limitations, I wondered if the PR asv would work better for those of us that are sensitive to the resmed pressure fluctuations responding ineffectively to non passive flow limitations (like chin tucking, plm - at least according to my theory-, and maybe uars?).

maybe only one way to find out. think I'll be on the lookout for a used PR asv.

[Gideon]

Note the PR ASV maintains Tidal volume vs Minute Vent (ResMed).

[sheepless]

thank you. that's a level of detail I'm not up to speed about. I'm not sure what it means in application. does that tell you anything about what conditions might be better served by PR machines?

[JoeyWallaby]

Pretty tired today, not sure why? Been yawning a few times. I've included my Apple Watch sleep data. My waking temperature was 36.2 celsius.



SarcasticDave94, in regards to PLM, I don't think I have it or RLS. I don't move or jerk my legs or limbs in my sleep based off the camera recordings, I just toss and turn every so often. More than normal? Eh, I don't know. Maybe I should tally up how much I move around in my sleep.

I do sometimes feel like Homer Simpsons watching the reactor melt down and randomly pressing buttons



Geer1, do you know where to find the imported SD card data with OSCAR? I have it in OSCAR but don't have the raw data off the SD card.

Yea a slightly higher PS could probably help. The 5 PS window that the machine requires is annoying, I guess ideally I would have the min PS set at what good for normal breathing and the max PS at what is necessary to overcome CAs.

I could ask my doctor to trial me on low-dose clonazepam, they don't like prescribing it anymore because of addiction. Clonidine is interesting, it's on-label use is treating high blood pressure but it has many off-label uses.

If I had hypoventilation, you'd be able to see the minute vent gradually dropping throughout sleep I think.

I see what you mean, the pressure cycling does seem to be decreasing a little.

[JoeyWallaby]

Took 400mg of magnesium last night alongside usual PPI. Put the PS up just 1. Actually feel somewhat decent today. HRV is up which is nice. That first big movement on the sleep session chart is me waking up for a second from a nightmare lol.

[Geer1]

Oscar data is saved under documents, OSCAR_data, profile (then your profile if you have multiple). If you include all the files in that folder it is easiest to transfer and supplies all data but note any personal data you have entered into OSCAR will be included. If you just select the machine (Resmed xxxx...) if I remember right I can set up a fake profile then move data in.

After reviewing the data I was going to consider potentially increasing psmin slightly to see if there is any change. Since you already did I would leave it as is for a few days and then we can compare data and see if any improvement on breath waveforms, flow limitations, RERAs etc. I already see that it caused a bit more respiratory depression so I wouldn't go above 3 because of this. Higher min ps is only helpful if it is reducing obstructive apnea/hypopnea (which you don't have) or reducing RERA's and flow limitations (which you have minimal of and we need to determine if increasing PS even helps with this). Lower min ps is helpful in that it reduces the treatment emergent central apneas. There is a sweet spot and I believe it is somewhere between 2 and 3 for you.

You think you slept slightly better but the question is was that because of change to PS min or because of the large dose of magnesium? Or was it just because you had a better night of sleep for an unknown reason? That is the hardest part about this, you will never really be able to know if you have the correct settings based on a single night of data as there are too many factors and too much variability. You need to be comparing trends based on multiple days/weeks.

Has the aerophagia been noticeably better since handcuffing max PS? I know that was a regular complaint before.

One of the other things I was curious about is why you hyperventilate at the beginning of each night (when first starting the machine)? Do you think it is anxiety/panic attack related (worried not going to get a good sleep etc)? Try to relax and control your breathing when first starting treatment as just that moment of hyperventilation could be putting your body into a state of fight or flight which could affect sleep. If it is anxiety related then CBTi techniques would be good to work on. If it isn't I am interested to know why you think you breath like that (very deep very fast breaths).

[JoeyWallaby]

I posted my sleep study before but here it is again.
https://imgur.com/a/I4rkike

Important parts
Spontaneous arousals
9.3/hour
Respiratory arousals
4.3/hour
CA AHI
1.1
Hypopnea AHI
4.2

Geer1, I sent you some CPAP data.

Yea I'm not sure, magnesium probably helped a bit. I did exercise a bit during the day as well, that may contributed. I'll take some magnesium again tonight.

Aerophagia has improved, had almost none today. A few days ago it was pretty bad, but okay right now.

It doesn't feel like hyperventilating when I first put on the CPAP, I guess I'm just getting used to the feeling when I first put it on? I know it looks massive on OSCAR. I'll try to calm down the initial breathing.

I wonder if the CAs I experience would be classified as treatment-emergent?

[Geer1]

I wonder if the CAs I experience would be classified as treatment-emergent?

You didn't have them during sleep study and they get noticeably worse at higher pressure/PS (especially higher PS which makes sense). I am fairly certain they are treatment emergent centrals. 

They are brought on for one of two reasons. Either you have a high apnea threshold (CO2 level where central apneas start to occur) or you breath fine at lower pressure/PS and your CO2 levels are actually decreasing below a normal apnea threshold level when using these higher pressures/PS. I can't remember where but I have read/been told it only takes 6 cm of pressure support to effectively evacuate CO2 so it isn't surprising you have centrals at some of the high pressure supports you have tried. 

Regarding the hyperventilation like breathing, when you start up your breaths are like 2.5 times the amplitude of your normal breathing and at an increased rate. I often have 1 or 2 breaths like that but you do it for a minute or two. It is causing a massive MV spike at beginning of the night which then sets a high MV target which takes around 30 minutes to return back to a normal level. Try to consciously control breathing during that time and see if you notice anything.