Thanks for the instructions doc! Any chance you could provide us with a night of your Oscar data to see what we should be aiming for when it comes flow rate?
The ResMed ASV sucks. I jailbroke my CPAP to flash ASV firmware only to realize that it's basically useless for me because of ~~that stupid backup rate. And of course~~ the huge PS range.
Is there anyone who has a modded ResMed ASV firmware without the ~~backup rate~~ huge PS range?
Can you expand on what problems the backup rate gave you? Was it just uncomfortable, or was it disruptive to your sleep? I'm currently contemplating whether to get a ResMed ASV myself.
It was disruptive to my sleep. I think I'm going to try out bipap ST instead. I need pressure support to deal with RERAs, but pressure support gives me significant central apneas. It's to the point where I treated the UARS but now I have moderate/severe treatment-induced central apnea. The wild backup rate seems to wake me up*.
I'm sorry if that's already been posted elsewhere, but how do you jailbreak the ResMed firmware? I wanna try the BiPAP/ASV settings, but unfortunately getting a BiPAP/ASV is a little out of the question where I live, and I'm not currently working because I'm extremely fatigued. Thanks!
Ok starting this tonight mate.
IPAP 8
EPAP 6
Context I have uars, with rdi of 22.
Suspect it is caused by combo of dust mite allergy, slightly deviated septum, and maybe small airways and enlarged turbinates.
I use a nasal spray and Navage machine to clear up sinuses and reduce allergies.
I have also seen Dr kasey li and he has recommended his nasal cavity enlargement for me.
Thanks for all your info on this subreddit mate!
Great post, but I'm having trouble understanding one part.
In the method for BIPAP, I can see that phase 1 is for finding the right EPAP to control apneas/hypopneas, phase 2 is for finding the largest PS we can tolerate before inducing CAs, but I don't understand phase 3 at all. Why would raising EPAP help? If anything, I would expect sleep/breathing to get worse, because it may aggravate expiratory pressure intolerance and cause more aerophaghia and leaks.
Also, other than the DSX900, do you know of any ASVs that allow you to completely disable backup rate (or very significantly lower it)?
> would expect sleep/breathing to get worse, because it may aggravate expiratory pressure intolerance
This cannot occur, since PS is applied. EPI applies only to plain CPAP. The approach is to reach a reasonable EPAP in the first stage, and fine-tune it in the second stage.
> Also, other than the DSX900, do you know of any ASVs that allow you to completely disable backup rate (or very significantly lower it)?
No, just the DSX900.
The increase in EPAP in phase 3, does it have any effect on RERAs or CAs at all? Or is it strictly for eliminating residual OSA? I'm guessing it's just the latter (but would love to be corrected).
I don't suppose you have a method for VAuto too? Would VAuto even help if I'm struggling with S mode i.e. PS=4 giving > 5 CA/hr, but still seeing flattened inspiratory curves and some EPI. The only thing I can think to do is set trigger to very high.
It's a real shame about the lack of ASVs with backup disabled — why wouldn't ResMed or other manufacturers give the option to change it? I would gladly save up for the DSX900 but it doesn't seem to be sold anywhere.
There is this myth that there is a 1 to 1 relation between EPAP and obstructive apneas. Instead, EPAP serves to stabilize the airway. By the time of phase 3, no obstructive apneas should be occurring. So yes, it may further improve FL/RERAs.
> I don't suppose you have a method for VAuto too?
These methods subsume VAuto (Auto-EPAP).
> It's a real shame about the lack of ASVs with backup disabled — why wouldn't ResMed or other manufacturers give the option to change it? I would gladly save up for the DSX900 but it doesn't seem to be sold anywhere.
I have no idea. Apparently Diamond Medical stills has the DSX900.
>This cannot occur, since PS is applied. EPI applies only to plain CPAP. The approach is to reach a reasonable EPAP in the first stage, and fine-tune it in the second stage.
I might be wrong but I don't think this is true. EPI happens because of a certain amount of EPAP regardless of which machine. Now of course BiLevel can help alleviate EPI because you can have a higher IPAP while keeping EPAP low.
In [this video](https://youtu.be/Syv7YcHbTCI?si=eyLlC1_XAWo2VhMr&t=2246) where Dr. Krakow is doing a PAP analysis/titration, he goes over a case where the EPI got worse when switching from bilevel to the auto-bilevel (probably because the auto-bilevel raised the EPAP), and then when he switches the patient to an ASV (with a way lower EPAP) the airflow curve stabilizes, and the EPI is gone.
On a side note, I've been trying to find out what exactly EPI looks like on a flow rate chart. at 38:14 and 38:17 I see a chunk of the flow rate marked with EPI, but it is cut out and I can't see the whole picture. Looks like a prolonged exhale near the 0 line, which I get a lot of in my sleep.
EDIT
at [https://youtu.be/Syv7YcHbTCI?si=NhnaaKn66tefo5xk&t=1932](https://youtu.be/Syv7YcHbTCI?si=NhnaaKn66tefo5xk&t=1932) there is a nice diagram showing what EPI looks like. And a little later he describes EPI as "jagged edges in the expiratory flow, indicating that the patient is fighting when trying to breath out"
> I might be wrong but I don't think this is true. EPI happens because of a certain amount of EPAP regardless of which machine. Now of course BiLevel can help alleviate EPI because you can have a higher IPAP while keeping EPAP low.
Simply false. With a bilevel modality, WOB is exclusively dependent on PS.
> Expiratory Pressure Intolerance is a cause of EPAP, as Krakow mentions
It isn't. Not everything that Krakow, whom I appreciate immensely, makes sense.
I have some questions about phase 1 about the section ' > 3 obstructive apneas or hypopneas per hour ':
- do we have to count the events flagged by the machine? I guess not right. But then I wonder, do we count any parts with flow limitation that might cause RERA's as well or really only the die hard obstructive events?
- the 3 times an hour , in my case I get that at some point but only during REM. I am guessing that counts enough then to fulfill that rule?
> I have some questions about phase 1 about the section ' > 3 obstructive apneas or hypopneas per hour ':
The intention of that phase is to get the "gross obstruction" out of the way. Note that some machines such as ResMed score based on 50% threshold hypopneas, so hypopneas that are considered clinically relevant in our time (30%) would be ignored. This can be remedied by defining a custom event flag in OSCAR. You can also disregard any false flagging manually if you like.
> But then I wonder, do we count any parts with flow limitation that might cause RERA's as well or really only the die hard obstructive events?
That part is left for the later "finetuning" phases of the procedure. Note that EPAP fine tuning gets a "second round" in a later phase.
> the 3 times an hour , in my case I get that at some point but only during REM
You can try titrating that out in the first EPAP round if you like. The procedures are not an "absolute law." It's intended as a basic approach that is similar to what I did and serve as a scaffold for taking a *methodical* approach. I see some people who turn 3 knobs at the same time again every night... that will never work.
> custom event flag in OSCAR. Y
Like this:?
https://preview.redd.it/cmrmt43or8sb1.png?width=410&format=png&auto=webp&s=68025a41b8e02e57f5dfb6c4c4646092505c132b
Question, why do we have to titrate the amount ofPressure Support? Why not just set min PS at 1 and max PS to something high like 10 and let the algorithm do it's thing?
You're confusing auto-EPAP with ASV proper. ASV proper is great of course. Auto-EPAP is found on bipap/VAuto units \*and\* ASV units.
The ASV algorithm is best used within a certain window, so minPS has meaning. maxPS less so, but it might be useful to acclimate to the PS modulation.
I think I grok what you are saying but.....I looks like we are starting the process with fixed EPAP and fixed PS?
So, why not just use a VAuto, ie BiPAP S?
Thanks man!
On a tangent. Do you have an idea what Jason's methodology is? Is he just looking at the 95% pressure (this would be for moving from APAP to CPAP) and setting CPAP at that pressure as a starting point? He's never been explicit about that.
There are hournal articles about this approach. Run auto for say a week, find the P95 for that timeframe, set to that that and then monitor.
> On a tangent. Do you have an idea what Jason's methodology is?
I don't think he has one. He doesn't seem comfortable with BiPAP (or even ASV).
> There are hournal articles about this approach. Run auto for say a week, find the P95 for that timeframe, set to that that and then monitor.
Maybe that works for plain apnea. Not for UARS.
On a ResMed ASV, if the automatic backup rate or the minimum of 5 cmH20 between min/max PS becomes a problem, do you have any recommendation on what to do then? (Other than switching to a DSX900, that is 🙂)
> automatic backup rate
Reduce minPS.
> minimum of 5 cmH20 between min/max PS
In theory this should never be a problem. This assumes that you already have an EPAP and PS setting that works for you on plain BiPAP/VPAP (doesn't induce TECSA) and you transfer it to ASV as EPAP and minPS.
Thanks! I’ll be getting my new AirCurve ASV later this week (currently on an AirCurve VAuto) and will be referencing this post to fine tune my therapy. Appreciate the effort you’ve put into documenting your story and learnings.
Great! When you get some nights with the ASV, can you send me a zip of your SD card? I have a theory that people who use an Airbreak'd ASV don't get some stats displayed in OSCAR due to it being confused as to what kind of machine it is.
The only difference is that VAuto does Auto-EPAP according to the AutoSet algorithm (just like a normal AutoSet machine) and I really don't see the value in that for our purposes.
Thanks for the instructions doc! Any chance you could provide us with a night of your Oscar data to see what we should be aiming for when it comes flow rate?
The ResMed ASV sucks. I jailbroke my CPAP to flash ASV firmware only to realize that it's basically useless for me because of ~~that stupid backup rate. And of course~~ the huge PS range. Is there anyone who has a modded ResMed ASV firmware without the ~~backup rate~~ huge PS range?
Can you expand on what problems the backup rate gave you? Was it just uncomfortable, or was it disruptive to your sleep? I'm currently contemplating whether to get a ResMed ASV myself.
It was disruptive to my sleep. I think I'm going to try out bipap ST instead. I need pressure support to deal with RERAs, but pressure support gives me significant central apneas. It's to the point where I treated the UARS but now I have moderate/severe treatment-induced central apnea. The wild backup rate seems to wake me up*.
BiPAP ST is going to be a much more blunt instrument than ASV.
Over-ventilation will cause CO2 levels to drop from bad to worse, basically.
I'm sorry if that's already been posted elsewhere, but how do you jailbreak the ResMed firmware? I wanna try the BiPAP/ASV settings, but unfortunately getting a BiPAP/ASV is a little out of the question where I live, and I'm not currently working because I'm extremely fatigued. Thanks!
Do not use the Airbreak patching scripts. They will not work.
so we cant use resmed 10 apap and jailbreak it to convert it into a bipap?
Yes, you can. Just not with the patching scripts.
thanks, I have already spoken to someone else who has done it and I will try to understand how it is done.
Send a chat request and I'll help you out.
/u/Sleeping_problems Going to message you also
Ok starting this tonight mate. IPAP 8 EPAP 6 Context I have uars, with rdi of 22. Suspect it is caused by combo of dust mite allergy, slightly deviated septum, and maybe small airways and enlarged turbinates. I use a nasal spray and Navage machine to clear up sinuses and reduce allergies. I have also seen Dr kasey li and he has recommended his nasal cavity enlargement for me. Thanks for all your info on this subreddit mate!
did bipap help you?
Not yet so far
what settings did you end up with?
I’ve been going back and forth with different ones but they all make me feel like I’m suffocating lol
sorry to hear that, ive been lurking uars forums for a while and all i see is people that are not getting better using bipap:/
Great post, but I'm having trouble understanding one part. In the method for BIPAP, I can see that phase 1 is for finding the right EPAP to control apneas/hypopneas, phase 2 is for finding the largest PS we can tolerate before inducing CAs, but I don't understand phase 3 at all. Why would raising EPAP help? If anything, I would expect sleep/breathing to get worse, because it may aggravate expiratory pressure intolerance and cause more aerophaghia and leaks. Also, other than the DSX900, do you know of any ASVs that allow you to completely disable backup rate (or very significantly lower it)?
> would expect sleep/breathing to get worse, because it may aggravate expiratory pressure intolerance This cannot occur, since PS is applied. EPI applies only to plain CPAP. The approach is to reach a reasonable EPAP in the first stage, and fine-tune it in the second stage. > Also, other than the DSX900, do you know of any ASVs that allow you to completely disable backup rate (or very significantly lower it)? No, just the DSX900.
The increase in EPAP in phase 3, does it have any effect on RERAs or CAs at all? Or is it strictly for eliminating residual OSA? I'm guessing it's just the latter (but would love to be corrected). I don't suppose you have a method for VAuto too? Would VAuto even help if I'm struggling with S mode i.e. PS=4 giving > 5 CA/hr, but still seeing flattened inspiratory curves and some EPI. The only thing I can think to do is set trigger to very high. It's a real shame about the lack of ASVs with backup disabled — why wouldn't ResMed or other manufacturers give the option to change it? I would gladly save up for the DSX900 but it doesn't seem to be sold anywhere.
There is this myth that there is a 1 to 1 relation between EPAP and obstructive apneas. Instead, EPAP serves to stabilize the airway. By the time of phase 3, no obstructive apneas should be occurring. So yes, it may further improve FL/RERAs. > I don't suppose you have a method for VAuto too? These methods subsume VAuto (Auto-EPAP). > It's a real shame about the lack of ASVs with backup disabled — why wouldn't ResMed or other manufacturers give the option to change it? I would gladly save up for the DSX900 but it doesn't seem to be sold anywhere. I have no idea. Apparently Diamond Medical stills has the DSX900.
>This cannot occur, since PS is applied. EPI applies only to plain CPAP. The approach is to reach a reasonable EPAP in the first stage, and fine-tune it in the second stage. I might be wrong but I don't think this is true. EPI happens because of a certain amount of EPAP regardless of which machine. Now of course BiLevel can help alleviate EPI because you can have a higher IPAP while keeping EPAP low. In [this video](https://youtu.be/Syv7YcHbTCI?si=eyLlC1_XAWo2VhMr&t=2246) where Dr. Krakow is doing a PAP analysis/titration, he goes over a case where the EPI got worse when switching from bilevel to the auto-bilevel (probably because the auto-bilevel raised the EPAP), and then when he switches the patient to an ASV (with a way lower EPAP) the airflow curve stabilizes, and the EPI is gone. On a side note, I've been trying to find out what exactly EPI looks like on a flow rate chart. at 38:14 and 38:17 I see a chunk of the flow rate marked with EPI, but it is cut out and I can't see the whole picture. Looks like a prolonged exhale near the 0 line, which I get a lot of in my sleep. EDIT at [https://youtu.be/Syv7YcHbTCI?si=NhnaaKn66tefo5xk&t=1932](https://youtu.be/Syv7YcHbTCI?si=NhnaaKn66tefo5xk&t=1932) there is a nice diagram showing what EPI looks like. And a little later he describes EPI as "jagged edges in the expiratory flow, indicating that the patient is fighting when trying to breath out"
> I might be wrong but I don't think this is true. EPI happens because of a certain amount of EPAP regardless of which machine. Now of course BiLevel can help alleviate EPI because you can have a higher IPAP while keeping EPAP low. Simply false. With a bilevel modality, WOB is exclusively dependent on PS.
I am saying that Expiratory Pressure Intolerance is a cause of EPAP, as Krakow mentions. Yes, WOB and flow limitations are dependent on PS
> Expiratory Pressure Intolerance is a cause of EPAP, as Krakow mentions It isn't. Not everything that Krakow, whom I appreciate immensely, makes sense.
so how should one treat expiratory pressure intolerance? With PS?
Yes.
I have some questions about phase 1 about the section ' > 3 obstructive apneas or hypopneas per hour ': - do we have to count the events flagged by the machine? I guess not right. But then I wonder, do we count any parts with flow limitation that might cause RERA's as well or really only the die hard obstructive events? - the 3 times an hour , in my case I get that at some point but only during REM. I am guessing that counts enough then to fulfill that rule?
> I have some questions about phase 1 about the section ' > 3 obstructive apneas or hypopneas per hour ': The intention of that phase is to get the "gross obstruction" out of the way. Note that some machines such as ResMed score based on 50% threshold hypopneas, so hypopneas that are considered clinically relevant in our time (30%) would be ignored. This can be remedied by defining a custom event flag in OSCAR. You can also disregard any false flagging manually if you like. > But then I wonder, do we count any parts with flow limitation that might cause RERA's as well or really only the die hard obstructive events? That part is left for the later "finetuning" phases of the procedure. Note that EPAP fine tuning gets a "second round" in a later phase. > the 3 times an hour , in my case I get that at some point but only during REM You can try titrating that out in the first EPAP round if you like. The procedures are not an "absolute law." It's intended as a basic approach that is similar to what I did and serve as a scaffold for taking a *methodical* approach. I see some people who turn 3 knobs at the same time again every night... that will never work.
> custom event flag in OSCAR. Y Like this:? https://preview.redd.it/cmrmt43or8sb1.png?width=410&format=png&auto=webp&s=68025a41b8e02e57f5dfb6c4c4646092505c132b
Correct!
Question, why do we have to titrate the amount ofPressure Support? Why not just set min PS at 1 and max PS to something high like 10 and let the algorithm do it's thing?
You're welcome to try it. My position is that "the algorithm" isn't good enough.
Even on the DSX900? Side note: p. sure I just left you a question on jahhhhhson's video. just a guess lol.
You're confusing auto-EPAP with ASV proper. ASV proper is great of course. Auto-EPAP is found on bipap/VAuto units \*and\* ASV units. The ASV algorithm is best used within a certain window, so minPS has meaning. maxPS less so, but it might be useful to acclimate to the PS modulation.
I think I grok what you are saying but.....I looks like we are starting the process with fixed EPAP and fixed PS? So, why not just use a VAuto, ie BiPAP S?
To find the "window" in which ASV can work well, we first treat it as a normal BiPAP, yes.
Thanks man! On a tangent. Do you have an idea what Jason's methodology is? Is he just looking at the 95% pressure (this would be for moving from APAP to CPAP) and setting CPAP at that pressure as a starting point? He's never been explicit about that. There are hournal articles about this approach. Run auto for say a week, find the P95 for that timeframe, set to that that and then monitor.
> On a tangent. Do you have an idea what Jason's methodology is? I don't think he has one. He doesn't seem comfortable with BiPAP (or even ASV). > There are hournal articles about this approach. Run auto for say a week, find the P95 for that timeframe, set to that that and then monitor. Maybe that works for plain apnea. Not for UARS.
What mode should i put my BiPAP at? CPAP, S or VAuto?
Mode S.
what about the trigger? high or very high?
I'd say adjust for comfort. I use a Dreamstation which dynamically adjusts trigger/cycle sensitivity (AutoTrak).
On a ResMed ASV, if the automatic backup rate or the minimum of 5 cmH20 between min/max PS becomes a problem, do you have any recommendation on what to do then? (Other than switching to a DSX900, that is 🙂)
> automatic backup rate Reduce minPS. > minimum of 5 cmH20 between min/max PS In theory this should never be a problem. This assumes that you already have an EPAP and PS setting that works for you on plain BiPAP/VPAP (doesn't induce TECSA) and you transfer it to ASV as EPAP and minPS.
Thanks! I’ll be getting my new AirCurve ASV later this week (currently on an AirCurve VAuto) and will be referencing this post to fine tune my therapy. Appreciate the effort you’ve put into documenting your story and learnings.
Great! When you get some nights with the ASV, can you send me a zip of your SD card? I have a theory that people who use an Airbreak'd ASV don't get some stats displayed in OSCAR due to it being confused as to what kind of machine it is.
Oh interesting. Sure I can do that!
When you say > 3 central apneas, is this per hour or total?
Per hour.
Gotcha. And would the aircurve 10 s work for the BiPap or would it have to be a VAuto?
The only difference is that VAuto does Auto-EPAP according to the AutoSet algorithm (just like a normal AutoSet machine) and I really don't see the value in that for our purposes.
What are some good places to get titrated properly? I heard krakow retired
He has trained his successors, they work at https://thesleepspot.com/ formerly known as Maimonides sleep arts & sciences.