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+--- Thread: [Treatment] Valtor Therapy Thread - from Autoset to Vauto (/Thread-Treatment-Valtor-Therapy-Thread-from-Autoset-to-Vauto)
Valtor Therapy Thread - from Autoset to Vauto - Valtor - 03-28-2024
Hello friends,
I have only started with APAP on March 15th. I was prescribed 6-14, but I felt I was not getting enough air on 6 so I initially increased it to 8-14.
I've tested different EPR and Ramp settings until I settled on EPR 3 Full Time and I keep the Ramp time on Auto with a start pressure that matches the min pressure just so that the machine does not start increasing pressure until I am asleep.
The first week I tried 8 different masks until I settled on the Nasal AirTouch N20 with mouth taping (KT Tape). That week was of course awful. I did not get much sleep.
I've been using OSCAR to try and reduce the pressure range, since large pressure changes seems to wake me up. I have settled on 11-14 at the moment. That keeps the RDI below 5 so far.
The reason I am asking for help now is that I am waking up as often if not more than before I started treatment. Seeing all hours of the night pass by is the reason why I consulted my physician in the first place.
Maybe you'll tell me that I just have to stick with it and it will improve over time. If so then great.
But if you guys spot anything in my chart that I should be made aware of, please do not hesitate to share. I would really like to experience what it is like to have a deeper sleep.
RE: Waking up 10+ times a night - Sleeprider - 03-28-2024
With a pressure setting of 11 to 14, EPR 3 your results are very good, with minimal changes in pressure, good respiratory statistics and low flow limitation. While obstructive events and flow limits are mostly resolved, you have sporadic OA and H events that seem to occur randomly, without warning. Typically such evnet will be preceeded by an increase in flow limits that will raise pressure, and you don't have that. A low frequency of CA events, mainly near the end of therapy appears unconnected to any specific problem and may be changes in sleep stage or physical movement. These may, or may not be consequential to your sleep quality. There are a number of respiratory spikes through the night that seem to coincide with leaks. We may want to zoom in to better understand those and the obstructive events.
In another post you indicated your CPAP is on rental and you expected to be charged at the end of the rental period to buy the device Normally insurance requires a device to be rented over a period of 13 months, at which time ownership of the device goes to the user without further charges. Noncompliance results in loss of the device, usually within 90 days of starting, and it is returned to the DME. You also asked about alternative machines including ASV. ASV is normally used to treat central apnea, but we have also seen it used increasingly for upper airway resistance with a high arousal rate. Spontaneous bilevel has more features and capability than CPAP at addressing UARS, flow limits and a high RDI, and can mitigate a low level of centrals by manipulating the trigger sensitivity where the device detects patient inspiration to trigger IPAP. ASV is comparatively hard to get as most doctors require a demonstration of need and a battery of heart tests, while something like the Vauto can be prescribed on the basis of comfort and sleep quality. If any of that remains of interest, we can talk about it in this thread.
RE: Waking up 10+ times a night - Valtor - 03-28-2024
Hello Sleeprider,
Thank you for your input. I was testing MedVance Silicone tape last night, but the seal is less adequate than KT tape for me. That might explain the leaks. I am including a couple zooms here.
Regarding the machine, it's a 3 month rental paid upfront where the rental cost will be deducted from the price of the machine if I keep/buy it. My insurance company only requires a proper prescription to reimburse 80% of the machine (max 3000 CAD$). I am not sure that they would issue a reimbursement for a machine bought online here in Québec Canada though. But I would not mind paying the full amount all by myself if that means I can get better treatment. So I would lose what I already paid for the rental, but would save quite a lot by not paying their 250% markup.
I am indeed pretty sure that my pulmonologist would not mind prescribing an auto BiPAP for reasons of comfort if I were to ask.
In any case, I still have ten weeks to figure it all out. I have an appointment with the respiratory therapist/provider this afternoon to buy a mask, since mine is just a loaner. I will pay them full price for a new AirTouch N20 (nearly 300 CAD$) because they were really forthcoming with loaning me many masks.
RE: Waking up 10+ times a night - Sleeprider - 03-28-2024
I think I'm seeing some inspiratory flow limits ahead of some of the CA events and the arousal at 04:14. I really need to get the resolution down to 3-4 minutes to see it and the closest zoom here is about 15 minutes. The OA at 04:30:35 has a large inspiration with breath-hold, and the expiration occurs just after the OA is flagged. That was a movement or roll-over, not an OA. The kinds of CA I'm seeing here should respond to use of the high or very-high trigger sensitivity in the Aircurve 10/11 Vauto.
RE: Waking up 10+ times a night - Valtor - 03-28-2024
Here are a couple 3-4 min zooms around flow limits.
Oh and I should mention that I am mostly a side sleeper. Original home test gave 7 AHI on side and 17 while on back.
RE: Waking up 10+ times a night - Valtor - 03-28-2024
So I'm back from my appointment with my respiratory therapist, and I do not know why I went because they did not have the AirTouch in stock.
But anyway, it turns out they are really unhappy that I changed the pressure settings on the APAP. Well, they'll just have to get used to it. They said they would note this in my report for the pulmonologist. I said no problem.
Who's going to look at this data and figure this out if I don't... no one. So that's that. Well ok, there's Sleeprider who's looking.
Anyway, they think the minimum of 11 is too high for me and that is causing the CAs. I did this because the 95% was around 11. But I might go back to 8-14 for a week and see how that goes.
With all that being said, I am not even sure my issue really is Apnea related. But at least the machine is providing good data. So running with 8-14 for a while would produce lots of usable data.
RE: Waking up 10+ times a night - Valtor - 03-29-2024
So in order to find out if 11 is indeed too much, I tried a night at fixed 7 no EPR at first, then I enabled EPR 2, then I increased to 8 because I was feeling starved for air on 7 even with EPR.
There is a lot of flow limit while EPR is off. Some leaks that I never became aware of because the seal seemed excellent all night and mouth was really tightly taped. The RDI is good as always. But I was waking up quite a lot yet again.
So to me this really means that fixed 7 or 8 is not cutting it based on those flow limits and OAs. I guess I could let the AutoSet do its thing and set it at 8-14 without EPR in order to try to tackle the CAs.
RE: Waking up 10+ times a night - Sleeprider - 03-29-2024
That last chart shot the flow limits from 0.01 to 0.09. You shouldn't need a specialty degree to know that's not a good movement. The closeups you provided are very good in resolution and give us a clear view of the inspiratory flow wave. Flow limitation is present, but may often be below the threshold of where the Autoset will sense or report it. Occasional arousals appear to be respiratory effort related. It's very subtle, but we have pretty much reached the practical limits of what CPAP can do with EPR 3, vs a true bilevel with more tools to work from. Your road to upgrade through insurance, consists of being persistent with complaints of sleep disruption and continuing fatigue as you follow-up with your doctor. The RT and DME will be of no help here. There is some good information on upgrading at the end of the Dealing With a DME wiki https://www.apneaboard.com/wiki/index.php?title=Dealing_with_a_DME and some good guidance and practical experience can be found in Deborah K's thread, Flow Limits, Upgrading from CPAP to Bilevel https://www.apneaboard.com/forums/Thread-Flow-Limits-How-to-Upgrade-CPAP-to-Bilevel&highlight=upgrade
You should return to your previous pressure range, and consider a slow titration upward of minimum pressure to see if it has any benefit. Your flow limits appear to respond to pressure, it's just easier and more comfortable to use pressure support. Your self-titration has clearly yielded measurable benefits to your sleep and comfort, so all I can say is keep up the good work, and use the linked articles to your best advantage if you want to upgrade.
RE: Waking up 10+ times a night - Valtor - 03-29-2024
Thank you very much for the feedback.
It so happens that in this life I am fortunate enough in that I can allow myself not to care much about the insurance.
But I guess that I still need an actual BiPAP prescription in order to get my hands on a device? No one is going to provide me with a BiPAP just because I have a prescription for an APAP right? So it will be a question of working with (convincing) my pulmonologist and the insurance would just be the cherry on top.
I can see that refurbished ResMed S10 AirCurve VAuto are 899 US$. I guess I could even get a used one if nothing else works.
RE: Waking up 10+ times a night - Sleeprider - 03-29-2024
As described in the articles I linked above, a prescription is easy peasy if you use your primary doctor (not a specialist), explaining your situation and dissatisfaction with CPAP and the continuing fatigue, sleepiness etc. and simply request a prescription for buying a Resmed Aircurve 10/11 Vauto (HCPCS# E0470) with initial settings of EPAP min 7.0, Max Pressure 12.0, PS 4.0. There are no required tests for spontaneous bilevel PAP and it can be prescribed and approved based on medical need for positive air pressure therapy and comfort considerations including continuing respiratory related arousals.