The more I try, the worse it gets.

[kaiasgram]

I don't think that auto mode will allow IPAP of 14 and EPAP of 10 with PS of 0.

Yes it will -- that's why I thought clarification might be important. Actually there is no PS in the "S" mode menu.

So what we don't know is if llian switched to "S" mode with IPAP=14 and EPAP=10, or if she just stayed in "VAuto" mode and decreased IPAP from 15 to 14 (and left the PS at 0). Big difference functionally so maybe worth clarifying again.

[Pugsy]

Yes it will -- that's why I thought clarification might be important. Actually there is no PS in the "S" mode menu.

So what we don't know is if llian switched to "S" mode with IPAP=14 and EPAP=10, or if she just stayed in "VAuto" mode and decreased IPAP from 15 to 14 (and left the PS at 0). Big difference functionally so maybe worth clarifying again.

I think I did that experiment myself and what I got was 10 inhale and exhale with the ability to go to 14 just like with APAP but I didn't get 14 while awake.
Remember my prior S9 VPAP settings were EPAP 10 PS of 4 and max IPAP of 20...so I saw 10/14 until I went to sleep.
Did you test it to see what it actually would do and not just what the machine settings were?
I actually did it for about an hour to test my theory that I could make it work like APAP...single pressure that would vary.
IPAP becomes max IPAP and essentially functions like maximum setting on APAP machine.
But that was well over a year ago when I did that experiment so I can't swear to the results but I think if you set your machine to 0 PS...in auto mode...I don't think you will see the change with inhale and exhale while awake and watching the screen...
Would you try it to confirm my memory or unconfirm it?

[kaiasgram]

Yes it will -- that's why I thought clarification might be important. Actually there is no PS in the "S" mode menu.

So what we don't know is if llian switched to "S" mode with IPAP=14 and EPAP=10, or if she just stayed in "VAuto" mode and decreased IPAP from 15 to 14 (and left the PS at 0). Big difference functionally so maybe worth clarifying again.

I think I did that experiment myself and what I got was 10 inhale and exhale with the ability to go to 14 just like with APAP but I didn't get 14 while awake.
Remember my prior S9 VPAP settings were EPAP 10 PS of 4 and max IPAP of 20...so I saw 10/14 until I went to sleep.
Did you test it to see what it actually would do and not just what the machine settings were?
I actually did it for about an hour to test my theory that I could make it work like APAP...single pressure that would vary.
IPAP becomes max IPAP and essentially functions like maximum setting on APAP machine.
But that was well over a year ago when I did that experiment so I can't swear to the results but I think if you set your machine to 0 PS...in auto mode...I don't think you will see the change with inhale and exhale while awake and watching the screen...
Would you try it to confirm my memory or unconfirm it?

I'm saying that if she kept the machine in VPAP Auto mode but left PS at zero, she will have APAP functionality. I think this is what you're saying your experiment showed. I think we're saying the same thing.

What we don't know is if she changed to "S" mode, in which case she'll have separate IPAP and EPAP, and both of those pressures will be fixed.

[Pugsy]

She'll be back and in a month...she will understand all this gibberish we have been talking if she doesn't have a TIA first.

I might go dig out my PR S1 760 just to reaffirm my theory because it works the same now that the 760 has a PS of 0 available in auto mode...actually a minimum and maximum.

[kaiasgram]

She'll be back and in a month...she will understand all this gibberish we have been talking if she doesn't have a TIA first.

I might go dig out my PR S1 760 just to reaffirm my theory because it works the same now that the 760 has a PS of 0 available in auto mode...actually a minimum and maximum.

I think I accidentally wiped out my "Who's On First" message.

Pugsy I believe we're saying the same thing. Unless she switched to "S" mode, her machine is acting like an APAP with a single pressure that can vary between 10 and 14 during the night.

[Pugsy]

Pugsy I believe we're saying the same thing. Unless she switched to "S" mode, her machine is acting like an APAP with a single pressure that can vary between 10 and 14 during the night.

Yep...we are saying same thing (I thought for a minute you weren't thinking on same page as me but I wasn't sure if I was misunderstanding you or if my memory was totally shot as to what the S9 VPAP in auto mode would do when PS was set to 0)...and I think when she said "fixed" she meant S mode because that is what she has been using.

[kaiasgram]

If she comes back we'll find out...
And if she doesn't come back I think I still have her phone number.
She can check in, but she can't check out!

[Pugsy]

She'll be back.
She's curious and wants to learn...she'll be back.

[kaiasgram]

She'll be back.
She's curious and wants to learn...she'll be back.

Totally agree.

[lliann]

She'll be back.
She's curious and wants to learn...she'll be back.

Totally agree.

Oh yes, I am totally on board with learning this. I have made a commitment to myself and some friends to really try to get my health figured out. I help people in another health category and my mia from the Doxepin really was felt.

But this will be a process. Last night what I did was changed back to fixed(s) and made it 14/10. Until I understand the process of the auto thing (Ill get it one of these days but sometimes it takes me a little longer to visualize) It felt like I breathed easier and I believe I did sleep for about 4 hours. (even through a big storm). I woke up with extreme itching on my foot. I have real itching issues that is why they were trying me on Doxepin. It stopped the itching but it stopped me too so I have been off it several weeks now. Then I was trying to reararrange my taking of Allegra from night to morning. And this itch thing showed up. Totally woke me from a sleep and still up 1.1/2 hours later waiting for the benadryl to kick in. I was going to send what I did manage last night but I didn't push in the damn card. I swear this apnea has turned me into the absent minded professor...er student.

So I will be back for sure. And I am grateful that I have you people willing to help me. But yes, I am curious too. You got my number alright.

[lliann]

So, I have a couple of autoimmune issues. So my health can be a bit of a moving target. Last night it moved. I was sleeping well, I thought, with the 14/10 s setting but my foot started itching in my sleep, I started scratching it in my sleep and I awoke in a full flare itch mode. (the reason why we were trying Doxepin) From there it expanded to my hands and generally a total feeling of being itchy.Took one Benadryl and it wasn't enough. Took another and that one knocked me out. I slept, got a reading, and here it is. So interesting feature. I did feel like I was breathing more comfortably. That my inhales and exhales didn't need to be forced as often to get enough air and fall asleep without thinking only of my next amount of air in the next breath. So it feels like that was a sign of going in the right direction. But again, I had 2 benadryls. Went into deep sleep and the centrals were up. Again, I wonder if being on a med like that suppresses breathing? (I am working with 3 different doctors from 3 different directions. I am the common denominator so I am trying to interpret any info I get to more than one issues. Sleep Apnea, asthma, another hormonal autoimmune issue and the itching.

Oh, one more thing. I used to have terrible dysphagia and that is part of why we kept trying to reduce my pressures. I am still getting the air but it is processing better. Instead of feeling like I have rocks in my stomach, I just spend a hour or so acting like a walking musical instrument.

so here we go with the second half of last night(actually like 630-1130 this morning) I did remember to push the damn data card in.

ResMed
S9 VPAP Auto
Mode: APAP 0-0cmH2O
Date Sleep Wake Hours
4/15/14 05:38 10:53 05:11:08
AHIApnea / Hypopnea Index 8.10
HypopneaHypopnea 0.39
ApneaUnspecified Apnea 0.00
ObstructiveObstructive Apnea 2.70
Clear AirwayClear Airway Apnea 5.01

Event Breakdown


Statistics
Channel Min Med 95% Max
EPAPExpiratory Pressure (cmH20)
W-Avg: 9.85 4.80 10.00 10.00 10.00
IPAPInspiratory Pressure (cmH20)
W-Avg: 13.85 8.80 14.00 14.00 14.00
Minute Vent.Minute Ventilation (L/min)
W-Avg: 5.21 1.75 5.12 7.50 11.88
Resp. RateRespiratory Rate (breaths/min)
W-Avg: 14.60 4.00 14.80 18.20 24.40
Resp EventsRespiratory Events
W-Avg: 0.00 0.00 0.00 0.00 0.00
Flow LimitFlow Limit Graph (0-1)
W-Avg: 0.00 0.00 0.00 0.00 0.17
LeaksLeak Rate (L/min)
W-Avg: 2.23 0.00 0.00 15.60 27.60
SnoreSnore (unknown)
W-Avg: 0.02 0.00 0.02 0.06 0.12
I:EInspiratory:Expiratory (ratio)
W-Avg: 42.19 7.00 41.00 61.00 84.00
Insp TimeInspiratory Time (seconds)
W-Avg: 1.21 0.56 1.20 1.44 1.70
Exp TimeExpiratory Time (seconds)
W-Avg: 3.01 0.98 2.84 4.42 8.08
Tidal VolumeTidal Volume (ml)
W-Avg: 355.47 60.00 340.00 540.00 700.00

Machine Settings
Pr. ReliefPressure Relief EPR x0

Session Information
SessionID On Date Start End
CPAP Sessions
1397554710ResMed CPAP 1h, 30m, 3s 4/15/14 05:38 07:08
1397560253ResMed CPAP 1h, 20m, 0s 4/15/14 07:10 08:30
1397565067ResMed CPAP 0h, 30m, 2s 4/15/14 08:31 09:01
1397566941ResMed CPAP 1h, 51m, 3s 4/15/14 09:02 10:53

[robysue]

lliann,

I'm sorry to hear about the autoimmune stuff and the itching. Sometimes we have to worry about issues other than the OSA and treat them even if it means doing some tradeoffs with the OSA.

You write:

But again, I had 2 benadryls. Went into deep sleep and the centrals were up. Again, I wonder if being on a med like that suppresses breathing?

The bigger problem remains the OAs and not the CAs. Your OAI was a whopping 12.37. Even if all the CAs were completely eliminated, you'd still have a problem with an AHI that was way, way too high.

It may be that the benadryl and deeper sleep lead to additional relaxation in the throat muscles. It could also be that more restless sleep (from the itching???) leads to more CAs. The point being: The CAs are what they are and they're not treated by fiddling with the pressure settings. If/when you start to get genuinely stable sleep without an excessive number of OAs, then the CAs may naturally come down in numbers.

The good news: The leaks are nicely controlled and you don't need to worry about them.

The bad news: There are still way too many OAs, which likely indicates your EPAP is not quite high enough.

You also write:

Oh, one more thing. I used to have terrible dysphagia and that is part of why we kept trying to reduce my pressures. I am still getting the air but it is processing better. Instead of feeling like I have rocks in my stomach, I just spend a hour or so acting like a walking musical instrument.

It's good the aerophagia (dysphagia) is becoming less of a problem. But the fact that you have a history of really painful "rocks in the stomach" aerophagia does mean that there's a real reason to try to minimize the overall pressure. Were you switched to a VPAP in part to see if it would help the aerophagia problems?

Given the aerophagia history and the fact that your current fixed pressure settings of IPAP = 14 and EPAP =10 don't seem to be adequately controlling the number of OAs, it is reasonable to consider a switch to VPAP Auto. But you write:

Last night what I did was changed back to fixed(s) and made it 14/10. Until I understand the process of the auto thing (Ill get it one of these days but sometimes it takes me a little longer to visualize)

I know that you're still a bit confused about how the VPAP Auto works. So let's work on an example that illustrates what you need to know in order to make a decision about whether to use AUTO.

Suppose you were to use the following settings in AUTO mode:

Min EPAP = 10
MAX IPAP = 17
PS = 4

These settings would induce the following two things:

Max EPAP = Max IPAP - PS = 17 - 4 = 13
Min IPAP = Min EPAP + PS = 10 + 4 = 14

Throughout the entire night your EPAP would be allowed to range from 10 to 13 cm H2O and your IPAP would range from 14 to 17 cm H20. At all times IPAP = EPAP + 4. In other words, the relationship between EPAP and IPAP would look like one of these pairs:

EPAP = 10, IPAP = 14 (at the beginning of the night)
EPAP = 11, IPAP = 15 (if there's a small increase in pressure)
EPAP = 12, IPAP = 16 (if there's an additional increase in pressure)
EPAP = 13, IPAP = 17 (at this point the machine won't increase the pressure any further)

The machine would automatically increase both EPAP and IPAP whenever any of the following happens:

• Clusters of two or more OAs and Hs. If two or more OAs or Hs occur within about a five minute period, the machine will increase the pressure. It will It will continue to increase the pressure until either the max setting (IPAP= 17/EPAP = 14) is reached or the events stop happening.
• Snoring. Any time there are peaks in the snoring graph, the machine will increase pressure. It will continue to increase the pressure until either the max setting (IPAP= 17/EPAP = 14) is reached or the snoring stops.
• Flow limitations. Any time there are peaks in the flow limitation graph, the machine will increase pressure. It will continue to increase the pressure until either the max setting (IPAP= 17/EPAP = 14) is reached or the inhalations smooth out and no longer look like they are "flow limited".

Once your breathing is stable (no OAs and Hs, no snoring, and no FLs), the machine will start lowering the pressure back down. On the VPAP Auto, IPAP and EPAP will decrease at rate. The machine will continue to decrease the pressure until either the min pressures settings (IPAP = 14/EPAP = 10) are reached OR [(more events occur or more snoring is detected or more FL are detected) and the pressure is increased once more]

The advantage of Auto mode is that when your breathing is actually stable, the machine will pretty much be running at 14/10, which your stomach can (mostly) tolerate. But when things start to deteriorate, the machine can respond and hopefully reduce the number of OAs that occur during the entire night.

Fewer OAs will likely mean better, more sound sleep. And that in turn should make you feel better.

[lliann]

Wow. thank you. I think I get it. I wonder if sometimes because I am not used to the terminology yet, my brain stops at the word. Today I was obviously sleepy. Thanks to the benadryl. But not near the sleep hangover I get with the Doxepin. I was taking 10 ml and Doxepin is the generic for Sinequan. I asked the doctor to get me a lower dose than 10 but the insurance said no to the Sinequan (which comes in 3 or 6) and to pay cash was something like in excess of $500). The doxepin is capsule only so I can't break it in half.

I really have dedicated myself to trying to find a way to manage these many issues. (exercise and diet is next. sigh)My complaint with the doctors is that so far they are each giving me individual bandaid solutions and I believe they have to factor in all the symptoms. Oh I forgot I also have high blood pressure (jeez, I am more of a mess than I thought) so there is that too. I have to take some responsibility for being an unwilling patient. I think I have been in denial about some of this but this year things got just a little worse. So I gave myself a good talking to and that is why I really am a willing student now. I won't let myself not come back.

Anyway, I understand what you said about how it works.(I think) I will try those settings tonight. Just to make sure you have all the info..because when I went into the auto set up there are 2 screens of potential settings. I will include them. I don't yet know how they all work (but I think I got the auto ipap/epap thing now ) and I don't know the math equation of how my events totalled 12.37, but I am trying to read all the tutorials you guys make available here (but it will take a little time as I am obviously a newbie to seriously trying to understand) and you guys wrote a lot!)

so in the auto screen:
mode- change to vauto

max ipap- change to 17

min epap- change to 14

PS- set at zero...I should change to 4?

Ti max- 2 (?)

Ti min- .3 (?)

Trigger- high(?)

Cycle- high(?)

max ramp- 45 min (oo question, if I put the mask and machine on, does it interpret data during the ramp or only once it stops?)

Start Epap- 4 (I think I may be confusing this with the PS?

The PS is the numerical limitation of pressure variation possible within the set setting? But only down for max and up for min?

I have a deviated septum and I think I taught myself over the year how to breathe shallow through my nose but when I fall asleep my breathing says go to the mouth. Since leaks in full face masks were a huge problem, thats when I started trying pillow/nose solutions but I am not sure how much pressure my little nose can take. But so far so good and I prefer the nasal for less real estate on my face. But yes, so far the aerophagia is there but not the problem (yet)I do the tape thing and I will wake myself up with chipmunk cheeks. I then expel through corner of my mouth and so far have been able to continue sleeping.

Anyway, this is so much info but I read one of your tutorials RobySue and it rightly pointed out while I am trying to interpret what you are saying, you are also having to interpret my beginning language.(it was more generic of course) So I will try to add my stray thoughts because and hopefully they won't continue to confuse all of us.

I am not sure where you all are. I am on the east coast so the timing of my replies may get longer the later it gets.



I finally picked up an oxymeter. How do I set that up on my machine because I bet the oxygen levels are a whole other thing.

[lliann]

I also want to apologize up front. Some of the questions I have have answers available in the many tutorials available here. I am seeking them out and printing so I can read but I think I ask my questions a little faster because we are being proactive?

[robysue]

Wow. thank you. I think I get it. I wonder if sometimes because I am not used to the terminology yet, my brain stops at the word.

Yep. That happens.

You ask about the settings. First of all, do you know all of the settings you are using in VPAP S mode? If not, then it would be wise to write down ALL the VPAP S settings in case you need to go "backwards" so to speak.

At any rate, here's what I think about what you should do with the VPAP Auto settings:

so in the auto screen:
mode- change to vauto

Yes, this will need to be done in order to use Auto mode.

max ipap- change to 17

min epap- change to 14

PS- set at zero...I should change to 4?

Yes. Change max ipap = 17, min epap = 14, and ps = 4.

[With PS = 0, all you've got is a glorified and expensive APAP machine rather than a VPAP Auto since PS = 0 means IPAP = EPAP all night long.]

Ti max- 2 (?)

Ti min- .3 (?)

Trigger- high(?)

Cycle- high(?)

I would compare these settings to the same Ti max, Ti min, Trigger, and Cycle settings you are currently using in VPAP S mode. These settings control how the machine changes from EPAP to IPAP and from IPAP to EPAP. So VPAP S also should have them.

I believe the default settings are Ti Max = 2; Ti Min = .3; Trigger = Med; Cycle = Med. Ti Max and Ti Min are measured in seconds; they represent the longest and shortest allowable times for the pressure to be at IPAP. If your inhalations often run longer than 2 seconds you may need to increase Ti Max some; otherwise the pressure may drop to EPAP while you are still inhaling.

Trigger controls when the machine will change from EPAP to IPAP; when set to HIGH it will trigger the change from EPAP to IPAP earlier in the inhalation than when it is set to MED.

Cycle controls when the machine will change from IPAP to EPAP; when set to HIGH it will trigger the change from IPAP to EPAP earlier in the exhalation than when it is set to MED.

max ramp- 45 min (oo question, if I put the mask and machine on, does it interpret data during the ramp or only once it stops?)

I'd set the ramp up the same way you have it set up in VPAP S mode. But to answer your question: Resmed machines do NOT flag events that happen during the ramp period. Nor will a Resmed machine running in Auto adjust the pressure upward if several events happen very close together when you are still in the ramp period.

Start Epap- 4 (I think I may be confusing this with the PS?

You may indeed be confusing Start EPAP and PS. Start EPAP is the starting RAMP pressure. If you don't use the ramp (i.e. RAMP time = 0), then Start EPAP is irrelevant.

The PS is the numerical limitation of pressure variation possible within the set setting? But only down for max and up for min?

Not quite. PS = IPAP - EPAP. It's the difference between the EPAP and IPAP pressure. So if EPAP = 11cm and PS = 4, then IPAP will be 11+4 = 15cm. On the Resmed VPAP, the PS is the constant difference between IPAP and EPAP even when you are running in Auto mode.

To make it clearer: If min EPAP = 10, max IPAP = 17, and PS = 4, then min IPAP = 14 and max EPAP = 13 and the possible pressure combinations are:
EPAP = 10 and IPAP = 10 + 4 = 14
EPAP = 11 and IPAP = 11 + 4 = 15
EPAP = 12 and IPAP = 12 + 4 = 16
EPAP = 13 and IPAP = 13 + 4 = 17

But if min EPAP = 10, max IPAP = 17, and PS = 3, then min IPAP = 13 and max EPAP = 14 and the possible pressure combinations are:
EPAP = 10 and IPAP = 10 + 3 = 13
EPAP = 11 and IPAP = 11 + 3 = 14
EPAP = 12 and IPAP = 12 + 3 = 15
EPAP = 13 and IPAP = 13 + 3 = 16
EPAP = 14 and IPAP = 14 + 3 = 17

Since your current pressures are IPAP = 14 and EPAP = 10, you are used to a PS = 4, and that's why I'd suggest setting PS = 4 in VAUTO mode.

I finally picked up an oxymeter. How do I set that up on my machine because I bet the oxygen levels are a whole other thing.

That's something someone else will have to help you with since I don't use an oxymeter.