[Treatment] ASV settings for treatment of complex sleep apnea

[JoeyWallaby]

LPR messes up your sinuses https://www.sciencedirect.com/science/ar...4603000038

I've had non-allergic rhinitis for years, low and standard dose PPIs don't do much. I'm thinking of trying high-dose PPIs for a short period and see if that improves my UARS/sleep apnea.

Gaviscon before bed seems to help my sleep but the problem is it only lasts like two hours, three or four at the most. So the first portion of sleep may be improved but the last portion isn't. If the PPIs improve my OSCAR data and tiredness, obviously I can conclude LPR is a significant aggravating factor.

I'm going to get another scope to look at my stomach and throat. I had chronically inflammed tissue around the opening of the lower esophageal sphincter in my last one. 

I also posted that I visited an ENT earlier, he said there was nothing wrong or interesting, except that base of my tongue was larger than normal.

[RayBee]

LPR messes up your sinuses https://www.sciencedirect.com/science/ar...4603000038

I've had non-allergic rhinitis for years, low and standard dose PPIs don't do much. I'm thinking of trying high-dose PPIs (omeprazole 40mg twice a day) for a short period and see if that improves my UARS/sleep apnea.

Gaviscon before bed seems to help my sleep but the problem is it only lasts like two hours, three or four at the most. So the first portion of sleep may be improved but the last portion isn't. If the PPIs improve my OSCAR data and tiredness, obviously I can conclude LPR is a significant aggravating factor.

I'm going to get another scope to look at my stomach and throat. I had chronically inflammed tissue around the opening of the lower esophageal sphincter in my last one. 

I also posted that I visited an ENT earlier, he said there was nothing wrong or interesting, except that base of my tongue was larger than normal.

You said these issues are not from allergies. Maybe you have already gone down this road, but I have been reading a few books from Dr. Joel Fuhrman M.D. on diet. He has used diet changes in thousands of patients to reverse and cure diabetes, heart disease, and countless autoimmune disorders. I was just reflecting on what I had read in his books as I was wondering if your rhinitis could be reversed and cured by following his nutrient-rich diet plan.

It seems like one of Dr. Fuhrman's biggest taboos is meat and dairy products (there are several others too). He still uses some meats as a meal garnish a few times per week, but not the main focus of meals. I like his books because they are pretty easy reads. He cites numerous studies on thousands of test subjects carried out over 20+/- years. As opposed to other doctors' studies typically based on very small groups (35 or 50, fill in a number here) and tainted by other contributing factors that skew data toward desired results.

I have been changing my diet to just lean toward his recommended nutrient-rich (yes I am a work in progress) and with just a half-hearted effort, my cholesterol has dropped from 244 to 170. Changes like this give me a boost to try harder and make dietary changes to better my health with food choices, as opposed to drugs and surgeries.

Like I said, you may have already been down this road before. But if not, I hope it is an option that may help improve your health in this and other areas of concern. All the best Joey.

[JoeyWallaby]

Have done plant based before and other diets but seems to have minimal effect 

Started PPI two days ago, breathing was really choppy last night. Today tired.

[Sleeprider]

I don't know what it means, but there is an inverse relationship of pressure support to respiration rate, and this is mainly due to high expiration time when PS is higher (expiration time is positively correlated to pressure support). Tidal volume and minute vent are steady. I'm pretty sure the PS increases are related to the slowing respiration rate, and the ASV is maintaining minute vent. This suppressed respiration rate is noticeable many places, but an example is 3/29 at 16:45, 17:00, and 20:30-22:00.

[Geer1]

I don't know what it means, but there is an inverse relationship of pressure support to respiration rate, and this is mainly due to high expiration time when PS is higher (expiration time is positively correlated to pressure support). Tidal volume and minute vent are steady. I'm pretty sure the PS increases are related to the slowing respiration rate, and the ASV is maintaining minute vent.  This suppressed respiration rate is noticeable many places, but an example is 3/29 at 16:45, 17:00, and 20:30-22:00.

It has always been there, the higher his PS goes the lower RR goes. His minute vent isn't steady, it is declining but hard to see because he always has high minute vent peaks. If he sets minute vent scale fixed at 0-10 and increases size of that chart then it will be more obvious. If you look closely will notice they almost always follow a moment of high amplitude breathing and a minute ventilation spike that I believe causes ASV to target a higher ventilation then his body needs once it settles back into sleep. I am not sure what causes this high amplitude breathing, I thought maybe a combination of centrals and high PS during them. His PS then stays high (slowly lowering) while minute vent slowly drops until eventually his spontaneous breathing takes over again and PS drops back to normal. I've always been curious about how he would perform on a machine that targets a minimum minute ventilation as I believe it could potentially improve this but I don't think he should waste money on such a machine or attempt to titrate one on his own as I don't even know that this is an issue. A long time ago when I was looking at his data in greater detail I looked at some other peoples ASV charts and saw similar so I don't think it is necessarily a problem, I think it is a byproduct of the basic way these ASV machines are programmed. They aren't smart enough to know when they need to remain elevated so end up being elevated longer than they need to be. The only way I recommend proceeding further would be to get a PSG/titration study so at least decisions and changes can be based on data.  

This is also the reason I keep being interested in how he would do when handcuffing PS max. If it still kept his centrals under good enough control it would reduce these periods of over ventilation and any effects they may be having on him. It has always been unclear if ASV is actually helping him get better sleep so I don't think it hurts to try, won't be near as bad as PS 9 on bilevel. Can't remember min settings but I would be tempted to try EPAP 4, PS min 3, PS max 6 or something like that just to see what happens. I think his treatment emergent centrals are an issue and although ASV is somewhat meant to treat them I think it is battle vs a smooth treatment. If we make it less of a battle by reducing treatment emergent centrals (with lower pressure and support) then I theorize it could help his sleep quality.


Joey,

A lot of the little blips and weird breaths you posted close up views of are other sleep disturbances that are then causing an effect on breathing. I have similar every 5-15 mins and when I video myself it is related to micro arousals, twitches and stuff like that. Your body takes a break from breathing properly as it settles back into sleep and then your breathing can look can look even stranger because of the variable PS and backup rate kicking in at those times. One of the difficulties with analyzing ASV data is knowing what is deciphering what is spontaneous breathing and what is the machine. That is where PSG data would come in helpful as they would be able to see if my theory is correct and those moments are following EEG or EMG events. 

As mentioned lower PS/handcuffed machine is my only advice for something to try. All of my other advice required doctors in the form of PSG data or prescription trials.

My only other advice would be to try antimicrobial treatment for SIBO. Candibactin AR and BR would be a good one to try. SIBO could be your cause of IBS, LPR, sleep disturbances and more. PPI's rarely work for LPR unless you also have GERD symptoms and if it is SIBO/dysbiosis related then the PPIs will make it worse not better. I do these antimicrobial treatments every once in a while now because it and the diet changes are the only thing that have provided any noticeable improvement in my health. I just started reading a book called Healthy Gut, Healthy You and it is the best source I have found for explaining all the potential gut issues, how everyone is different and how they can be hard to diagnose and treat. Has a decent plan to try and figure out issues and improve. I bought a kindle version which was only like $10, money well spent if you have gut issues.

[JoeyWallaby]

Felt okay 31st March, probably because I slept for so long but not good today because I kept waking up near the end of sleeping last night. Probably because of the pressure going crazy up and down.

It's annoying how it crashes PS instead of lowering it slowly, I guess due to using a rolling average of minute vent as a target 

I don't know what it means, but there is an inverse relationship of pressure support to respiration rate, and this is mainly due to high expiration time when PS is higher (expiration time is positively correlated to pressure support). Tidal volume and minute vent are steady. I'm pretty sure the PS increases are related to the slowing respiration rate, and the ASV is maintaining minute vent.  This suppressed respiration rate is noticeable many places, but an example is 3/29 at 16:45, 17:00, and 20:30-22:00.

Indeed with lower pressure I have a faster breathing rate, here's some of those windows you specified.

---

It has always been there, the higher his PS goes the lower RR goes. His minute vent isn't steady, it is declining but hard to see because he always has high minute vent peaks. If he sets minute vent scale fixed at 0-10 and increases size of that chart then it will be more obvious. If you look closely will notice they almost always follow a moment of high amplitude breathing and a minute ventilation spike that I believe causes ASV to target a higher ventilation then his body needs once it settles back into sleep. I am not sure what causes this high amplitude breathing, I thought maybe a combination of centrals and high PS during them. His PS then stays high (slowly lowering) while minute vent slowly drops until eventually his spontaneous breathing takes over again and PS drops back to normal. I've always been curious about how he would perform on a machine that targets a minimum minute ventilation as I believe it could potentially improve this but I don't think he should waste money on such a machine or attempt to titrate one on his own as I don't even know that this is an issue. A long time ago when I was looking at his data in greater detail I looked at some other peoples ASV charts and saw similar so I don't think it is necessarily a problem, I think it is a byproduct of the basic way these ASV machines are programmed. They aren't smart enough to know when they need to remain elevated so end up being elevated longer than they need to be. The only way I recommend proceeding further would be to get a PSG/titration study so at least decisions and changes can be based on data.  

This is also the reason I keep being interested in how he would do when handcuffing PS max. If it still kept his centrals under good enough control it would reduce these periods of over ventilation and any effects they may be having on him. It has always been unclear if ASV is actually helping him get better sleep so I don't think it hurts to try, won't be near as bad as PS 9 on bilevel. Can't remember min settings but I would be tempted to try EPAP 4, PS min 3, PS max 6 or something like that just to see what happens. I think his treatment emergent centrals are an issue and although ASV is somewhat meant to treat them I think it is battle vs a smooth treatment. If we make it less of a battle by reducing treatment emergent centrals (with lower pressure and support) then I theorize it could help his sleep quality. 


Joey,

A lot of the little blips and weird breaths you posted close up views of are other sleep disturbances that are then causing an effect on breathing. I have similar every 5-15 mins and when I video myself it is related to micro arousals, twitches and stuff like that. Your body takes a break from breathing properly as it settles back into sleep and then your breathing can look can look even stranger because of the variable PS and backup rate kicking in at those times. One of the difficulties with analyzing ASV data is knowing what is deciphering what is spontaneous breathing and what is the machine. That is where PSG data would come in helpful as they would be able to see if my theory is correct and those moments are following EEG or EMG events. 

As mentioned lower PS/handcuffed machine is my only advice for something to try. All of my other advice required doctors in the form of PSG data or prescription trials.

My only other advice would be to try antimicrobial treatment for SIBO. Candibactin AR and BR would be a good one to try. SIBO could be your cause of IBS, LPR, sleep disturbances and more. PPI's rarely work for LPR unless you also have GERD symptoms and if it is SIBO/dysbiosis related then the PPIs will make it worse not better. I do these antimicrobial treatments every once in a while now because it and the diet changes are the only thing that have provided any noticeable improvement in my health. I just started reading a book called Healthy Gut, Healthy You and it is the best source I have found for explaining all the potential gut issues, how everyone is different and how they can be hard to diagnose and treat. Has a decent plan to try and figure out issues and improve. I bought a kindle version which was only like $10, money well spent if you have gut issues.

You're referring to iVAPS above I assume? I was just reading about that before, I was wondering about that as well. The ASV handles CAs well but the oscillating pressure swings aren't nice, I don't know why it does that so much. Is it an intended response to disordered breathing (possibly caused by blood gas imbalances) or just going crazy trying to target the rolling average minute vent, who knows? Maybe I should try EERS or acetazolamide sometime again.

But as you said, iVAPS has a lot more settings, which can be as good as it can be bad... trying to find the right settings isn't easy. 


In regards to handcuffing PS max, the lowest the ASV lets me set the Max PS is 5 above the Min PS. The lowest Min PS goes is 0, so the lowest Max PS can be is 5. Or 1-6, 2-7, 3-8, 4-9, etc.

I'm going to ask my doctor about another gastroscopy and another sleep study. Also I need to set up my night vision camera so I can look at what I'm doing when the pressure is going crazy. I had a camera setup before and I found it helpful to match the video to the breathing, I'm going to do that again, maybe I'm doing something positional during my sleep that messes me up.

The PPIs have been helping with LPR somewhat, I know they're bad long-term and also they definitely cause some digestion issues. Amazing how many people have GERD/LPR but the treatments are still pretty archaic. My LPR definitely isn't caused by obesity because I'm skinny, I have the UARS profile of physicality. Skinny, narrow palate, little bit of teeth crowding, young, normal neck size, etc... versus the OSA profile of overweight, older, large neck.

I was on antibiotics a few weeks ago for an ear infection, that seemed to help my sleep subjectively. I have some cascara sagrada bark extract that supposedly has an antimicrobial effect on the gut, I was thinking of trying some activated charcoal as well, since obviously you can't just take antibiotics all the time.

I have acne and I can use whatever skincare products, anything you can think of, but the only things that actually clear it up are topical antibiotics, oral antibiotics or topical azelaic acid and benzoyl peroxide (both antimicrobial). So, having some kind of gut dysbiosis with stomach bacteria wouldn't surprise me. 

Talking about how ASV works, targeting a rolling average of the last few minutes of minute vent, here's the charts of minute vent for the last five days. You can see how much it struggles.

[JoeyWallaby]

This is the study I was thinking about with pressure oscillations, they actually refer to it as pressure cycling.

https://academic.oup.com/sleep/article/4...login=true

The examples they provide

[Geer1]

Post some minute vent graphs from your bilevel with a setting of 4-6 EPAP and ~4 PS. I am curious to see how they differ from the ASV ones (to understand how much the variation is due to ASV and how much is spontaneous).

I would try EPAP of 4, PS min 2, PS max 7. You have tried everything else but I don't believe you have tried something like that. I believe ASV theory is flawed at least in some patients. It tries to treat CPAP induced centrals by increasing pressure and ventilation which is what induces the centrals to begin with. I called it a battle before but cycling like that study calls it is the same idea. You have to try and find the sweet spot where you are getting enough ventilatory support without fighting the machine all night.

I would try to get your hands on that gut book (I got kindle version off Amazon and you can use free program on computer to read it). The more you read the more it will probably make sense. I learned almost all of it from other sources but actually sitting down and reading it laid out and tied together like he does made everything click and he provides studies to back up his theories if interested in that. Everyone has a lot of the same symptoms but the cause is always different, stress, alcohol, caffeine, food sensitivity/allergy, autoimmunity, parasite, poor motility, poor diet and more can all have the same affects on gut which then provides the same symptoms to person (fatigue, disturbed sleep, reduced hormone production and more). In my research I would say doctors know less about how our gut works than our brains do, it is so complicated most doctors don't even try. Mine just looked at me and said probably IBS, thanks Sherlock... The fact that medicine has combined all functional gut issues into a single 3 letter diagnosis tells you how little they know on the subject.

[JoeyWallaby]

Sure

Minute vent on bilevel

[JoeyWallaby]

Changed the settings and took 500mg extended release acetazolamide last night.

Gotta get the camera setup, I think some of the choppiness is me rolling onto my back and it being harder to breathe. I fall asleep on my side always but obviously move around when I'm sleeping.