Is my new RESMED S9 APAP Defective...or?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Marc76Law
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Is my new RESMED S9 APAP Defective...or?

Post by Marc76Law » Fri Sep 17, 2010 3:32 am

I was diagnosed with severe sleep apnea in May 2010 and was prescribed a Respironics System One APAP (4-14) with Swift FX nasal pillow mask. Without getting into too much detail that is not directly relevant, the sleep study in May showed that I had developed severe form of primarily obstructive apnea but a lot of the apmeas were mixed/complex and some were central. (Previously overnight sleep tests ans MSLTs showed some clinically insignificant central apneas. So prior to May 2010, I had been diagnosed with primary idiopathic hypersomnia (one sleep doctor said it wasn't really that much different than narcolepsy, I fell asleep in under 4 minutes for each of the naps in the MSLT but went into n-rem rather than rem sleep. If I had gone into Rem, then it would have been called narcolepsy),

The reason for the sleep test in May was that I found myself to be absolutely exhausted and unable to function no matter how much sleep I got. The previous dosages of stimulant medication I had been prescribed and never had to exceed in six yuears (from May 2004 to 2010) became ineffective. That I had primary hypersomnia as indicated on three previous sleep tests was not something that wad in need of verification. Rather, the sleep doctor was trying to see if the cause of the profound exacerbation in my symptoms would show up. Luckily it did, and the CPAP made a tremendous difference within only a a few days.

(I still required stimulant medication for my primary hypersomnia but it was easily controlled with a low dose of medication).

A few days I decided to purchase the Resmed S9 APAP (humidifier and climate hose) since my health insurance has lousy DME coverage the rental copay (50 %) for the Respironics turned out to be $125 a month. My sleep doctor wrote the RX for the new machine at (4-14) and I kept the Swift FX nasal pillow mask to use with the Resmed.

UNFORTUNATELY, I THINK THAT I RECEIVED A DEFECTIVE MACHINE. I called the company (one of the ones that is in the top 5 results when you google CPAP machines) and explained that I thought the machine was defective and provided the following information:

I like to read in bed before going to sleep and because I often will fall asleep while reading, I put on the CPAP mask and turn on the machine while reading my book. I have never used the RAMP feature and made sure it was turned off. I expected to be able to read my book and fall asleep without any discomfort yet 25 minutes later, my nose felt like someone was blowing a hose down it. I checked the LCD screen on the Resmed and the pressure had reached 13.5. I turned the machine off and it when it restarted, it was steady at 4.0 again. I turn out the lights to go to bed and notice once again (15 minutes later perhaps) that the pressure had increased and sure enough according to the Resmed LCD, the pressure 9.5.

My understanding is that any APAP machine (both my PR system one and this new Resmed - if set to 4 to 14 in APAP mode) will begin blowing at 4.0 and only increase pressure, as needed by detecting apneas which of course, don't start until I fall asleep. Thus, I concluded that my Resmed S9 was defective as I hadn't fallen asleep, nor had I snored, stopped breathing, or otherwise given any cause for the Resmed to increase its pressure.

I call the company and explain the above to customer service. The agent tells me that its possible (likely actually) that the machine is fine and that the most likely explanation was that a setting had been entered incorrectly. When I was asked to mail the memory card in, I said that I could just download the data and either email it to them or print out all the data into a report for them. I only had six nights of data and thus included every possible option in the Resmed report. (I also made sure and was indeed correct that the mode was APAP and that ramp set to OFF.

I received the following response from the customer service department in a reply email.


Mr. Fellman,

After reviewing your report it is really best that you follow up with your physician. It doesn't appear that your machine is doing anything abnormal, however you do show signifigant apnea events and big leaks. Your physician should be able to help figure this out and help fit your mask better. Please let us know the results of your physician visit so we can better help you with your therapy. The following codes are needed to submit to your insurance for reimbursement.



Unfortunately, my doctor is out of town until next week, and I find the response confusing and ambiguous. If you would like to see the exact report that I compiled from Resmed to send them, cllck on either of the links below (sorry about the 60 second wait). If you understand the Resmed graphs and data, is the company right that the machine is working as it's supposed to? If so, why? are they saying that I am having apneas while I am awake? Or that the leak is to blame. All my attempts to get back in touch with customer service were ignored.

If anyone can help me understand, you have my sincerest thanks in advance. (Either of those links provides the PDF file the company asked me for and from which they claim to know the machine is working correctly)

http://rapidshare.com/files/419551775/C ... EPORTZ.pdf
http://hotfile.com/dl/69951027/2aa876f/ ... Z.pdf.html

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billbolton
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Re: Is my new RESMED S9 APAP Defective...or?

Post by billbolton » Fri Sep 17, 2010 4:55 am

Marc76Lae wrote:UNFORTUNATELY, I THINK THAT I RECEIVED A DEFECTIVE MACHINE.
You have been attempting to use the S9 in a way it was never intended to be used, so the results you have been experiencing are most likley a direct result of that, rather than a defect.
Marc76Lae wrote:I like to read in bed before going to sleep and because I often will fall asleep while reading, I put on the CPAP mask and turn on the machine while reading my book.
Any APAP machine is designed to respond to autonomous sleep breathing only. What happens when you are not asleep is an undefined state for any APAP system and the results you experienced are not particularly unusual under the circumstances, especially given the extremely wide range of the titration range.

Your DME should have explained the use of an APAP system to you, the setting options that are available and the use of features such as Ramping etc.

Given the particular set of syndromes you seem to be suffering from, you need to find a sleep clinician with a better understanding of APAP treatment approaches.

Cheers,

Bill

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greg-g
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Re: Is my new RESMED S9 APAP Defective...or?

Post by greg-g » Fri Sep 17, 2010 6:55 am

I never really trust ResScan's interpretation of events. I much prefer to expand out the high resolution flow rate data and see what is actually happening. A 5 minute scale is probably best.

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Marc76Law
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Re: Is my new RESMED S9 APAP Defective...or?

Post by Marc76Law » Fri Sep 17, 2010 12:43 pm

The reason I put the machine on when I get in bed to read is that if I wait until I think I am getting sleepy, I will almost inevitably fall asleep with the light on and the book in my lap and thus won't have had a chance to put on the mask. I realize ti's bad sleep hygiene to be reading in bed before falling asleep, but I've also had the same thing happen even when turning on the machine and getting into bed immediately to fall asleep. I tend not to fall asleep quick;y and the Resmed will shoot to a high a pressure and make me uncomfortable before I even fall completely asleep.


For some reason, this didn't happen with the Respronics System One which almost never would get above 4.5 until I had actually fallen asleep for the night,

While I didn't post my previous sleep data, up until recently I had responded very well to CPAP, My AHIs were down from the 30s to below 10, sometimes below 5. I've also lost 35 pounds since May and it's almost certainly the case the part of why I developed the severe apnea was dramatic weight gain (60 pounds) in fall of 2009. My expectation was that by losing the weight, my OSA would resolve and I'd be cured of my sleep apnea and need for CPAP,.

What appears to be the case is that mt central apneas - which had always been miild and clinically insignificant - are becoming a bigger part of the problem, I've read that treating mixed apnea with CPAP can sometimes cause precisely such a result. In fairness to my doctor, whom I really like, he hasn't had an oipportunity to review this new development or the data I sent the DME and his office, HE mentioned the possibility of me needing an ASV when I first started CPAP therapy but since when I last saw him a month ago, I had appeared to have an excellent response to APAP,

Until I can get in touch with my doctor, I was hoping to get some help here. I'm new and apologize if this is mentioned elsewhere but caN anyone help me with the followingL:


1. I am overwhelmed with the Resmed detailed data. I do not understand at all some of the categories like:

Flow
Minute Ventilation
Flow Limitation

What is the clinical relevance of this information? I have no problem following pressure, leak, AHI, or events - although with EVENTS, they occur so close together its hard to tell what exactly is going on other than I'm having apneas.

Is there any sort of comprehensive tutorial or guide to understanding the DETAIILED DATA provided by Resmed like Flow, Flow Limitation, and Minute Ventilation.

2. Why am I suddenly experiencing such mask leak problems, when I've been used the same Swift Nasal pillow mask for months. The leaks don't seem to be a problem to me until the pressure gets really high, and if the mask leaks are what is causing the pressure ti get high, it seems like I'm not really clear on the problem stil.

Could it be that I need a different mask for these higher pressures, and if so, can anyone recommend one to me. I prefer nasal pillow or cushions masks rather than full face.

3. Would a solution to my habit of reading in bed with mask and CPAP on be to use the Ramp feature set to 45 minutes - since I'm usually asleep within that period of time. What I'm trying to do is keep the pressure low until I fall asleep so that then and only then can the machine increase the pressure up to the levels it has been?

4. Can anyone recommend the easiest way to post data on the message board in the form of graphs in order to get feed back from the group> Since there are so many options for viewing the ResMed data in detail, is there a preferred time interval or type of data to include? Is there a better website than rapidshare or hotfile to use?


Thank you for those of you who have responded. I am learning a lot.

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Slartybartfast
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Re: Is my new RESMED S9 APAP Defective...or?

Post by Slartybartfast » Fri Sep 17, 2010 1:02 pm

I think your machine is fine. I have one and when the ramp feature is set very short, or turned off, pressure can go high as the machine responds to your irregular breathing while awake. The machine has no way of knowing whether you're awake or asleep. The ramp feature is there to ensure that you have had sufficient time to drift off to sleep before the machine starts making pressure adjustments. If you turn off the ramp feature, you're asking for it.

My prescription specified 11 cm. I've run my S9 in constant pressure mode at 11 cm for about a week with the ramp set at 20 minutes which is enough for me to get to sleep. In auto-mode I experimented with setting the ramp at 5 minutes or off, and found that the pressure varies unpredictably (to me), because the machine is responding to irregularities in my breathing while awake.

Again, try setting the ramp to 45 minutes or so and you'll be fine.

JohnWayne
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Re: Is my new RESMED S9 APAP Defective...or?

Post by JohnWayne » Fri Sep 17, 2010 4:07 pm

For ResMed's information on understanding detailed data Google ResMed "Data Management Guide".

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dave21
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Re: Is my new RESMED S9 APAP Defective...or?

Post by dave21 » Sat Sep 18, 2010 12:15 pm

Marc,

I think it would help us better if we could see your graphs. The S9 will score events within the RAMP time afaik, the RAMP is there only to just make the pressure more bearable, the machine isn't used to really be used when you're awake and reading with it as Bill suggests. You could get some false results like central apneas appearing because you're in control of you're breathing but you're more likely to hold your breath now and again and that could be triggering central events on the graph.

If you're seeing central apnea events within the time frame you're reading then that's probably why, and pressure will increase. Likewise the same if it thinks you're having breathing difficulties with obstructive apneas.

For most of us however, Apneas don't usually occur within the first hour of sleep onset. For me I usually find that it takes 3-4 hours before I get into the zone of having apneas.

Hope this helps.

Thanks
Dave

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billbolton
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Re: Is my new RESMED S9 APAP Defective...or?

Post by billbolton » Sat Sep 18, 2010 5:18 pm

dave21 wrote:The S9 will score events within the RAMP time afaik...
No, it doesn't
Resmed S9 Clinical Guide wrote: Ramp

Designed to make the beginning of treatment more comfortable, ramp is available in both CPAP and AutoSet modes.

Ramp time defines the period during which the pressure gradually increases from a lower more comfortable start pressure to the minimum AutoSet pressure before the auto-adjusting algorithm commences. In previous products in the AutoSet range, settling was the period where the device was at a minimum AutoSet pressure until the auto-adjusting algorithm commenced.
... also Marc76Lae explicitly said....
Marc76Lae wrote:I have never used the RAMP feature and made sure it was turned off.
dave21 wrote:If you're seeing central apnea events within the time frame you're reading then that's probably why, and pressure will increase.
APAPs generally don't respond to central apneas at all, and specifically the S9 certainly doesn't.

Cheers,

Bill

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