Newbie Seeking Path Forward

[Pugsy]

You can check back in daily if you wish...don't go more than 2 or 3 days though...I am an old woman and I forget what I told somebody sometimes.

[Julie]

Your min. pressure is the machine's default low setting and most of us literally cannot breathe at that level - not enough air coming in! I suggest you try bumping it to e.g. 7 (which is still low as things go) for a few nights. I doubt you'll suddenly get a flood of centrals as a result, but can almost guarantee you'll be able to breathe a lot more naturally. A few nights shouldn't make much of a difference to anything otherwise.

[Pugsy]

Your min. pressure is the machine's default low setting and most of us literally cannot breathe at that level - not enough air coming in! I suggest you try bumping it to e.g. 7 (which is still low as things go) for a few nights. I doubt you'll suddenly get a flood of centrals as a result, but can almost guarantee you'll be able to breathe a lot more naturally. A few nights shouldn't make much of a difference to anything otherwise.

No...the minimum pressure is 8 cm but it shows 4 on the statistics because ramp is used which starts at 4 cm.
He never mentioned not being comfortable at 4 cm starting point.
He's using a fixed pressure machine anyway...you need to look at the pressure graph and not just the statistics.

[Pugsy]

and what is the green line that hovers at 6

Red line (top line on pressure) is inhale pressure.
Green line is the exhale pressure since Flex exhale relief is being used. The most Flex will drop (even at a setting of 3 ) is 2 cm....so even if his setting was 3 he gets the max of 2 cm reduction. Hence the green line hovering at 6 cm.
Respironics Flex exhale relief is based on flow...or how forcefully a person happens to breathe. Shallow breathers may not get the full 2 cm max even at the setting of 3. We are never told how much the max is for the setting of 2 Flex...but I would assumed less than 2.

He might be using Smart Ramp and if that is the case if the airway tries to close the machine will suspend ramp and increase the pressure up to the 8 cm fixed setting and then reduce it once the airway opens back up IF there is remaining ramp time available.

[Pugsy]

dont know about smart ramp

Smart ramp is the term for Respironics machine ramp that senses when the airway is trying to close and does something about it.
Regular ramp does not except in Auto mode. Smart ramp is new to the DreamStation model line. Wasn't available on the older models but older models in auto mode have done it since I think at least the M Series models. So not totally new but now it has a name where with the older models in auto mode it did it but had no special name to it and in fact if someone didn't read the clinical manual closely they could miss it.

ResMed has something similar called Auto Ramp on the AirSense/AirCurve machines. It's a special menu option in addition to regular ramp.

[Hammer]

Hi.

Just to provide some input on my ramp process. I usually lay in bed reading or watching TV and then as soon as I feel the least bit drowsy I put on the mask, turn on the machine and hit the ramp. As correctly diagnosed, the ramp starts at 4 and then works its way to 8 within 30-minutes. I can hit the ramp again if I'm still awake, but by then Ive acclimated to the higher pressure level and rarely do so. I was not aware there was an auto ramp setting on this unit. In fact, I remember the home health company telling me that when I got it the downside to this machine was that it did NOT have an auto ramp like the ResMed units.

[Pugsy]

In fact, I remember the home health company telling me that when I got it the downside to this machine was that it did NOT have an auto ramp like the ResMed units.

Too bad they don't know the ins and outs of their machines. To be fair though Smart Ramp is not exactly like ResMed's Auto Ramp.
ResMed says their Auto Ramp will go to minimum pressure setting as a result of sensing that a person is asleep and then of course presumably deal with the apnea events. Respironics says it just deal with them but one has to assume that you won't have apnea events if you are not asleep.
End result is the same though. Now how accurate ResMed might be in determining if someone is asleep or not is a topic for a different discussion.

Below is what I found in the provider/clinical manual for the DreamStation machines where it talks about Smart Ramp. There's another section that shows that Smart Ramp is available in cpap and apap modes.

[robysue]

Hammer,

I'm sorry that you are not yet feeling well.

I just read this whole thread. I apologize in advance for the fact that this response is lengthy and probably has yet more questions for you to answer. Also, please note that I've interleaved your various posts together in the way I want to address them.

First of all:
In response to xxyz, you write:

what did the first sleep tests show That I had both central and obstructive

We need to know more about those initial sleep tests. Do you have the full summary report? The summary report includes both the summary data (how many events and what types) as well as the summary graphs (the hypnogram and an event table that show when the events happened. If you do not have a copy of the full summary report, I suggest that's where to start: Request it from the lab that did the test or the doc that authorized the test. It will usually run somewhere between 3 and 7 pages, and you may be asked to pay a small per page fee of about $1 per page for the report.

Once you have the summary report, the things you need to tell us are:

• The total number of obstructive apneas (OAs), central apneas (CAs), hypopneas (H), and respiratory effort related arousals (RERA) scored on the diagnostic test (or the diagnostic part of a split test, if you had a test where they put the CPAP on you in the middle of the night.)
• The index numbers---i.e. the OAI, CAI, HI, and RERA I, for the diagnostic test. The index numbers are average number of events per hour of sleep: If you had 100 OAs in 3.75 hours of sleep, the OAI would be reported as 100/3.75=26.7 since the index numbers are typically rounded to one decimal place.
• The total number of events and the index numbers on the titration test---i.e. the same two sets of numbers for the test (or part of the test) where they had a CPAP mask on your nose.

The importance of having these numbers in front of us is that it will end the speculation about whether the CAs are frequent enough to be a huge issue, a middle sized issue, or not a very big issue. And that is important in sorting out what xPAP therapy advice to give to you.

Next, you posted a detailed daily data chart at http://imgur.com/36pipv8. On this night, the number of CAs was pretty low (CAI = 1.28) and the CAs that occurred were pretty spread out throughout the night. In other words, if this night is pretty typical of your data, then you don't seem to be experiencing the long clusters of CAs that typically indicate ineffective treatment of a CA problem.

On this night, you also have an overall AHI = 3.83, which is below the 5.0 that is used to officially declare the apnea is well treated. That doesn't mean you might feel better with a lower AHI, but it does mean that the AHI is well enough under control that other, non-apnea causes of bad sleep need to be considered in trying to tease out what needs to happen before you start to feel better.

You also posted overview data for 4/17 - 7/16 at http://imgur.com/1aLvty4. The AHI data on this chart shows that your CAI (the purple part of the AHI bar) is always below 3.0, and usually well below 3.0. The largest component of your long term AHI seems to be Hs. They could be central hypopneas, or they could be obstructive hypopneas. If they are obstructive hypopneas (which are far more common), then a smidge more pressure might make a big difference in bringing your AHI numbers down. If they are central hypopneas, however, even a small pressure increase might cause you to have more central hypopneas and more CAs. Hence without seeing your data from the sleep tests, I am reluctant to suggest that you change the pressure on your machine.

Third, in response to a question by pugsy you write:

Hours of Sleep: Machine says over the last 90-days 5hrs 39mins- It takes me 30-45 mins to fall asleep, a few wake ups at night, awake for 45mins-1hr before alarm. My guess would be about 4 hours.

Four hours of sleep on a nightly basis is enough to leave ANYBODY feeling exhausted, fatigued, and unable to focus on daily tasks. So it's not really a surprise that you are "still fatigued, still exhausted, and still can 't focus on tasks."

In other words, until you are actually sleeping 6-8 hours with the machine every night, it's not reasonable to expect to feel much different.

And so the important question becomes: What can you do that will help you get enough sleep to actually feel better?

You have written:

Current Meds: Ambien 1-2 times per week, Synthroid daily

Hours of Sleep: Machine says over the last 90-days 5hrs 39mins- It takes me 30-45 mins to fall asleep, a few wake ups at night, awake for 45mins-1hr before alarm. My guess would be about 4 hours.

I used to have issues falling asleep, but continuous Ambien therapy changed that and for a while I had no insomnia. About 6-months after stopping Ambien completely I started to have early morning awakenings usually 3:30-4:00 AM. Went back to Ambien as needed (1-2 times/week) some days keeps me asleep till 6:00AM some days not.

So you've got some problems with insomnia, in the sense getting to sleep with the mask on (up to 45 minute for sleep latency), staying asleep (a few wake ups at night), and waking up too early.

And you are taking Ambien "as needed" 1-2 times a week. What makes you decide that you need to take an Ambien on a given night?

I've got a whole bunch of insomnia related questions so please bear with me.

1) What does your typical sleep schedule look like? Do you have a regular bedtime? A regular wake up time? If so, what are they?

2) You say it takes you 30-45 minutes to get to sleep with the mask on. How uncomfortable do you get during that period? Any dry mouth problems during that period?

3) When you take the Ambien, do you get to sleep any faster? If so, how much faster?

4) How many wakes do you usually remember when you wake up in the morning? 2 or 3? Or more like 5-6? When you take the Ambien, do you remember fewer wakes?

5) When you wake up 45-60 minutes before your alarm goes off and you can't get back to sleep, how uncomfortable are you with the mask on? Is your mouth exceptionally dry at that point?

6) When you wake up in the middle of the night, what's the first thing you do? Look at the clock? Start calculating how little sleep you've gotten so far? Start worrying about how little time there is before you have to get up the next morning?

7) If the Ambien was working well, was there a reason you discontinued it? In other words, would you be willing to start taking Ambien every night if it helped you get more sleep and more continuous sleep with the CPAP?

8) How much caffeine and alcohol do you consume on a daily basis? How late into the day/evening do you consume caffeine and/or alcohol?

9) Do you get some exercise on a regular basis? Even something as short as a 15-20 minute walk around the neighborhood can make you feel and sleep better.

10) Do you get some outside light each day?

Finally I'll offer a bit of very NONtraditional advice for what to try next: I think that your ongoing problems with fatigue and daytime brain fog are more likely caused by the fact that you are only getting about 4 hours of actual sleep, even if you are in bed for substantially longer than that. I suspect that fixing the insomnia will make it much easier to tolerate the CPAP, and that you will only feel better during the daytime when both the insomina and the sleep apnea are kept under control. The data indicates your CPAP is doing a decent job of managing your apnea, but your statements indicate that you do indeed have an insomnia problem even if that's not how you think about it.

Here's what I would suggest:

1) Use SleepyHead's notes area to keep a very simple sleep log. Each morning make a note of how much sleep you think you actually got during the night and how well you feel when you get up. Also track whether or not you took an Ambien. You need to tease out whether you feel better, worse, or about the same after the nights you take Ambien.

2) After a couple of weeks, start looking at the data in your sleep log for any patterns that stand out. My guess is that you may discover you sleep better on the nights that you take the Ambien---if you take the Ambien early enough in the night to not have a rough start of the night.

3) Consider going back to taking Ambien every night for a week or two. See if taking it continuously rather than "as needed" helps you sleep longer than your current 4 hours/night. If taking the Ambien every night helps you get more like 6-7 hours of sleep, then in time you should start to feel better.

Good luck with reining in your insomnia problem.

[Hammer]

Hammer,

I'm sorry that you are not yet feeling well.

I just read this whole thread. I apologize in advance for the fact that this response is lengthy and probably has yet more questions for you to answer. Also, please note that I've interleaved your various posts together in the way I want to address them.

First of all:
In response to xxyz, you write:

what did the first sleep tests show That I had both central and obstructive

We need to know more about those initial sleep tests. Do you have the full summary report? The summary report includes both the summary data (how many events and what types) as well as the summary graphs (the hypnogram and an event table that show when the events happened. If you do not have a copy of the full summary report, I suggest that's where to start: Request it from the lab that did the test or the doc that authorized the test. It will usually run somewhere between 3 and 7 pages, and you may be asked to pay a small per page fee of about $1 per page for the report.

Once you have the summary report, the things you need to tell us are:

• The total number of obstructive apneas (OAs), central apneas (CAs), hypopneas (H), and respiratory effort related arousals (RERA) scored on the diagnostic test (or the diagnostic part of a split test, if you had a test where they put the CPAP on you in the middle of the night.)
• The index numbers---i.e. the OAI, CAI, HI, and RERA I, for the diagnostic test. The index numbers are average number of events per hour of sleep: If you had 100 OAs in 3.75 hours of sleep, the OAI would be reported as 100/3.75=26.7 since the index numbers are typically rounded to one decimal place.
• The total number of events and the index numbers on the titration test---i.e. the same two sets of numbers for the test (or part of the test) where they had a CPAP mask on your nose.

The importance of having these numbers in front of us is that it will end the speculation about whether the CAs are frequent enough to be a huge issue, a middle sized issue, or not a very big issue. And that is important in sorting out what xPAP therapy advice to give to you.

Next, you posted a detailed daily data chart at http://imgur.com/36pipv8. On this night, the number of CAs was pretty low (CAI = 1.28) and the CAs that occurred were pretty spread out throughout the night. In other words, if this night is pretty typical of your data, then you don't seem to be experiencing the long clusters of CAs that typically indicate ineffective treatment of a CA problem.

On this night, you also have an overall AHI = 3.83, which is below the 5.0 that is used to officially declare the apnea is well treated. That doesn't mean you might feel better with a lower AHI, but it does mean that the AHI is well enough under control that other, non-apnea causes of bad sleep need to be considered in trying to tease out what needs to happen before you start to feel better.

You also posted overview data for 4/17 - 7/16 at http://imgur.com/1aLvty4. The AHI data on this chart shows that your CAI (the purple part of the AHI bar) is always below 3.0, and usually well below 3.0. The largest component of your long term AHI seems to be Hs. They could be central hypopneas, or they could be obstructive hypopneas. If they are obstructive hypopneas (which are far more common), then a smidge more pressure might make a big difference in bringing your AHI numbers down. If they are central hypopneas, however, even a small pressure increase might cause you to have more central hypopneas and more CAs. Hence without seeing your data from the sleep tests, I am reluctant to suggest that you change the pressure on your machine.

Third, in response to a question by pugsy you write:

Hours of Sleep: Machine says over the last 90-days 5hrs 39mins- It takes me 30-45 mins to fall asleep, a few wake ups at night, awake for 45mins-1hr before alarm. My guess would be about 4 hours.

Four hours of sleep on a nightly basis is enough to leave ANYBODY feeling exhausted, fatigued, and unable to focus on daily tasks. So it's not really a surprise that you are "still fatigued, still exhausted, and still can 't focus on tasks."

In other words, until you are actually sleeping 6-8 hours with the machine every night, it's not reasonable to expect to feel much different.

And so the important question becomes: What can you do that will help you get enough sleep to actually feel better?

You have written:

Current Meds: Ambien 1-2 times per week, Synthroid daily

Hours of Sleep: Machine says over the last 90-days 5hrs 39mins- It takes me 30-45 mins to fall asleep, a few wake ups at night, awake for 45mins-1hr before alarm. My guess would be about 4 hours.

I used to have issues falling asleep, but continuous Ambien therapy changed that and for a while I had no insomnia. About 6-months after stopping Ambien completely I started to have early morning awakenings usually 3:30-4:00 AM. Went back to Ambien as needed (1-2 times/week) some days keeps me asleep till 6:00AM some days not.

So you've got some problems with insomnia, in the sense getting to sleep with the mask on (up to 45 minute for sleep latency), staying asleep (a few wake ups at night), and waking up too early.

And you are taking Ambien "as needed" 1-2 times a week. What makes you decide that you need to take an Ambien on a given night?

I've got a whole bunch of insomnia related questions so please bear with me.

1) What does your typical sleep schedule look like? Do you have a regular bedtime? A regular wake up time? If so, what are they?

2) You say it takes you 30-45 minutes to get to sleep with the mask on. How uncomfortable do you get during that period? Any dry mouth problems during that period?

3) When you take the Ambien, do you get to sleep any faster? If so, how much faster?

4) How many wakes do you usually remember when you wake up in the morning? 2 or 3? Or more like 5-6? When you take the Ambien, do you remember fewer wakes?

5) When you wake up 45-60 minutes before your alarm goes off and you can't get back to sleep, how uncomfortable are you with the mask on? Is your mouth exceptionally dry at that point?

6) When you wake up in the middle of the night, what's the first thing you do? Look at the clock? Start calculating how little sleep you've gotten so far? Start worrying about how little time there is before you have to get up the next morning?

7) If the Ambien was working well, was there a reason you discontinued it? In other words, would you be willing to start taking Ambien every night if it helped you get more sleep and more continuous sleep with the CPAP?

How much caffeine and alcohol do you consume on a daily basis? How late into the day/evening do you consume caffeine and/or alcohol?

9) Do you get some exercise on a regular basis? Even something as short as a 15-20 minute walk around the neighborhood can make you feel and sleep better.

10) Do you get some outside light each day?

Finally I'll offer a bit of very NONtraditional advice for what to try next: I think that your ongoing problems with fatigue and daytime brain fog are more likely caused by the fact that you are only getting about 4 hours of actual sleep, even if you are in bed for substantially longer than that. I suspect that fixing the insomnia will make it much easier to tolerate the CPAP, and that you will only feel better during the daytime when both the insomina and the sleep apnea are kept under control. The data indicates your CPAP is doing a decent job of managing your apnea, but your statements indicate that you do indeed have an insomnia problem even if that's not how you think about it.

Here's what I would suggest:

1) Use SleepyHead's notes area to keep a very simple sleep log. Each morning make a note of how much sleep you think you actually got during the night and how well you feel when you get up. Also track whether or not you took an Ambien. You need to tease out whether you feel better, worse, or about the same after the nights you take Ambien.

2) After a couple of weeks, start looking at the data in your sleep log for any patterns that stand out. My guess is that you may discover you sleep better on the nights that you take the Ambien---if you take the Ambien early enough in the night to not have a rough start of the night.

3) Consider going back to taking Ambien every night for a week or two. See if taking it continuously rather than "as needed" helps you sleep longer than your current 4 hours/night. If taking the Ambien every night helps you get more like 6-7 hours of sleep, then in time you should start to feel better.

Good luck with reining in your insomnia problem.

[Hammer]

OMG. I just spend the last 40 minutes responding to your post and my changes did not save. UGH! Will try again later.

[robysue]

Hi.

Just to provide some input on my ramp process. I usually lay in bed reading or watching TV and then as soon as I feel the least bit drowsy I put on the mask, turn on the machine and hit the ramp. As correctly diagnosed, the ramp starts at 4 and then works its way to 8 within 30-minutes. I can hit the ramp again if I'm still awake, but by then Ive acclimated to the higher pressure level and rarely do so. I was not aware there was an auto ramp setting on this unit. In fact, I remember the home health company telling me that when I got it the downside to this machine was that it did NOT have an auto ramp like the ResMed units.

The feature is called a Smart Ramp and it is set to On or Off inside the clinical menu.

When the Smart Ramp is set to ON, the pressure does NOT increase during the ramp period until one of the following occurs:

1) Events start to happen and the machine responds (like Pusgsy said)
2) Just before the ramp period ends and the pressure ramps up to the therapeutic pressure setting in less 2-5 minutes or so if I recall correctly. (At least that's what happens with my machine.)
3) The breathing becomes very, very regular and the machine concludes that you are asleep and starts to ramp the pressure up over the remaining ramp time.

If the constant increase in pressure during the ramp period does not bother you while you are awake, then there's no real need to switch to the Smart ramp on your machine.

If the constant increase in pressure during the ramp period makes it more difficult for you to get to sleep in the first place, then turning on the Smart ramp feature can be very useful.

[robysue]

OMG. I just spend the last 40 minutes responding to your post and my changes did not save. UGH! Will try again later.

Been there, done that more times that I care to think about.

Two things can help:

1) When you log in, check the box that says "stay logged in" since there is an automatic time out feature that can kick in when you are writing response that takes a long time to write.

2) Get in the habit of copying all the text in the editing window on a long post before you try to preview or submit it. That way you can "paste" it back into the editing window if the computer decides to eat your post.

Also feel free to split your response to my questions across several shorter posts that take less time to write.

[robysue]

In fact, I remember the home health company telling me that when I got it the downside to this machine was that it did NOT have an auto ramp like the ResMed units.

Too bad they don't know the ins and outs of their machines. To be fair though Smart Ramp is not exactly like ResMed's Auto Ramp.
ResMed says their Auto Ramp will go to minimum pressure setting as a result of sensing that a person is asleep and then of course presumably deal with the apnea events. Respironics says it just deal with them but one has to assume that you won't have apnea events if you are not asleep.
End result is the same though. Now how accurate ResMed might be in determining if someone is asleep or not is a topic for a different discussion.

Below is what I found in the provider/clinical manual for the DreamStation machines where it talks about Smart Ramp. There's another section that shows that Smart Ramp is available in cpap and apap modes.

=======

could there be old/wrong info on the internet

i recall when i looked at the ramp on the resmed aircurve 10 vauto that it said it went from start to target over the set time
and that it did not change if you feel asleep sooner and had an apnea

The stuff Pusgy posted is about PR DreamStation CPAP/APAP/BiLevel machines because that's what the OP on this thread happens to own.

If you own (or have used) a Resmed AirCurve 10 vauto in the past, the information about PR DreamStations does NOT apply to your machine. The Resmed AirSense and AirCurve machines DO have a feature called Auto ramp. Whether it is turned On or Off depends on how the clinical settings are set. You need to get into the clinical set up menu if you want to explore the Auto ramp.

but then my machine was the dumbest cpap with exhale relief and there was NOTHING AUTO on it at all
it had ramp
but the machine forced me to breathe at its rate and did not adapt to my rate

You keep saying this, but at the same time, you also keep saying that you had a Resmed AirCurve 10 VPAP AUTO, which is capable of running in an auto-bilevel mode.

The simplest explanation of why you felt like the machine was forcing you to breath "at its rate" instead of adapting to your rate is that the Resmed EasyBreathe algorithm may just not feel right to you. Most people love the EasyBreathe algorithm, but a few (including me) find that it is NOT easy to breathe with in our particular situation. Switching to a PR machine may or may not feel better. In my case it helped. In your case? Who knows.

Finally it's important to remember that what the Resmed VPAP Autos do depends on exactly what the therapeutic settings are in the clinical set up menu. To more precisely explain your Resmed AirCurve 10 VAUTO's behavior, you would need to tell us all of the following things:

• Exact therapy mode: CPAP? APAP? VPAP? VAUTO? ST? T? (Those last two are NOT found on the ordinary AirCurve VPAP Auto, but they are found in more expensive VPAP ST machines.)
• Pressure setting(s): What's available depends on the mode. They include pressure, min pressure, max pressure, min EPAP, max IPAP.
• Pressure support or EPR setting: In VPAP or VAUTO mode, the PS setting is critical. In CPAP/APAP mode, the EPR setting is critical.
• EasyBreath: Is it set to On or Off? Is the timing set to "medium" or "fast"?
• Trigger sensitivity: This controls how pronounced the beginning of the inhalation needs to be to trigger the increase from EPAP to IPAP in the various VPAP modes.
• Cycle sensitivity: This controls how pronounced the beginning of the exhalation needs to be in order for the machine to cycle the pressure from IPAP back to EPAP.
• In the various ST and T modes: TiMin and TiMax settings are critically important in helping the machine respond to central events by timing the triggered inhalations correctly.

[robysue]

i say it because it was true

i know what the label claimed about vauto
but my experience was that it was not auto at all

What were the therapeutic settings? Until you are willing to discuss the therapeutic settings, you are badmouthing a machine that is known by many users to be a high quality machine that automatically adjusts the pressure both in terms of baseline EPAP and in terms of switching between EPAP and IPAP on every breath when run in VAUTO mode with a PS > 0 and max IPAP > (min EPAP + PS).

now maybe AHC turned auto off
back then i was not up on the clinic menu and how to change things
but the device i had was totally fixed and useless to me

You keep blaming the machine when you should be blaming the settings that the company that sold you the machine set it up with.

And even though you now know that with proper knowledge you could have gotten into the clinical menu and changed the settings, you still keep insisting the Resmed AirCurve 10 VAUTO is not an "auto" machine.

In other words, blame the DME who set your machine up, not the AirCurve 10 VAUTO itself, for how it felt when you were using it.

[Pugsy]

could there be old/wrong info on the internet

That information is from a Phillips Respiroinics Dream Station clinical manual/Provider guide that covers the CPAP PRO, Pro, Auto, BiPap Pro, BiPap Auto.
Dated October 2016.
It's accurate and not old and not wrong. Go over to the apneaboard and get it yourself if you don't believe me.

I have the AirCurve 10 VAuto manual also...I could do the same thing with it...actually read it and find the pertinent information and post it but I won't.
Why waste my energy...you won't believe it anyway. Why don't you go get the manual and see for yourself?
Your problems with the VAuto sounds like the DME set it up in fixed bilevel mode (did you know it has 3 modes?). Why did they do that? Don't know...ask them. But most likely it was set per the doctor's orders that was sent to them because that's what they have to do...follow the doctor's orders.
You blame everyone and everything but it was the doctor who went the settings...DMEs just set the machine up like the orders.

Again...get the manual and read for yourself since you don't seem to want to believe what someone else says.