My Periodic Soapbox Speech About Ramp

Every now and then I like to throw this out there for newbies who are using the ramp feature on their machines. Not fully understanding the implications in ramp use, my misuse was destructive to my sleep and nearly derailed my CPAP treatment. Ramp is a comfort feature for those who prefer it. Nothing wrong with using it if it's working for you. Just keep in mind every minute you are asleep while the machine is in ramp time, you are un/underprotected from apnea events. My early machine came set to a 45 minute ramp starting at a pressure of 4. (Later one came set for 30 minutes at 4.) My sleep deprivation was so extreme, I fell sound asleep before my head hit the pillow. Due to my struggle with limb movements and with feeling like I was suffocating, I woke every few minutes. The doctor and the tech at the DME had instructed me to just hit the ramp when I woke up. I didn't understand that this pretty much condemned me to spend most of my night at a pressure of 4 or just over that. My health took a nose dive after starting CPAP, and this was the main reason. Once I came here and and was advised to to shorten my ramp time and increase my ramp pressure, I began to turn around. I could keep the mask on for longer periods. My message is to use the ramp feature with knowledge and caution. If you think this may be a problem for you, do a little tally of how much time you sleep each night while under ramp. When I did that, it was an eye opener. I still use the ramp feature. It starts at a pressure of 9 for 5 minutes. Just long enough for me to settle in and get the coughing and throat clearing over and not be included in my data. Ok, off my soapbox for a few months. Just figure surely I'm not the only one with this experience.

Well said. I agree 100%.

Thanks for letting us newbies know that the ramp feature doesn't work for everyone. While I was waiting (several weeks ) to get my machine I read a lot on this forum and was prepared to possibly not like the ramp feature. I ended up shutting it off within the first half hour of my first night and have never turned it back on since.

I really don't get why doctors think the ramp feature is so great. Since when is a suffocating feeling comfortable? I get that they're trying to increase patient compliance, but subjecting a patient to 30-45 minutes of 4cm is likely to make many patients feel like they'll never be able to live with CPAP. I can't believe the bad advice you were given. Good for you for sticking with it even though your health became worse until you listened to the people here instead of to your doctor.

Thanks for all of the good advice. I've learned a lot from you.

my ramp time is set at 5 minutes....

it gives me time to get settled into bed before the 19 IPAP / 14.5 EPAP pressure fully kicks in.

That should not only be a Sticky, but you should still reprint it as a new post every 3 mos! I think that ramping should be pointed out to newbies as an available comfort feature (like EPR) only if someone complains of difficulty dealing with the initial few seconds of adjustment to the pressured air, rather than having it programmed to come on automatically (with no pre-explanation) or clarity about it's being unnecessary for 'therapy' in itself.

I started out at twenty minutes, quickly dropping to five because it just felt better.
When I got the AS10, I eliminated it entirely as an experiment of therapy vs run hours.
It felt natural to just leave it off. Getting the mask seated properly is good to get done right away.

Minky wrote: I really don't get why doctors think the ramp feature is so great.

Most docs have never tried to sleep with a CPAP machine.

And most docs don't spend the time trying to sort out what a newbie in trouble means when they say, "I can't breathe with the machine." And so they take the sales literature from the manufacturers that says, "Ramp is a comfort feature to allow the patient to breathe more comfortably when the patient is falling asleep" a bit too literally and tell the newbie to use the ramp anytime they wake up feeling uncomfortable.

But here's the thing: The phrase, "I can't breathe comfortably with the machine" can mean two very different things, and that's extremely important when trying to figure out how to help the newbie become compliant:

If the newbie is genuinely feeling overwhelmed by the amount of air being blown at them and cannot exhale comfortably when they are awake and trying (desperately) to get to sleep, the judicious use of the ramp can be very useful in getting the person over the hump.

If the newbie is genuinely feeling like they cannot inhale comfortably because there seems to be too little air in the mask to do that, then the ramp is a huge mistake.

I get that they're trying to increase patient compliance, but subjecting a patient to 30-45 minutes of 4cm is likely to make many patients feel like they'll never be able to live with CPAP.

I'd like to clarify an misconception here. If the ramp starts at 4cm and lasts for 30-45 minutes, you are NOT at 4cm the whole time. There is a linear increase in pressure from the time you turn the machine on to the end of the ramp period. Let's see what that looks like if your therapeutic pressure is set to 10cm (or your min pressure is 10cm if you are using an APAP) and you are using a 30 minute ramp from 4-10 cm: The pressure is increasing at .2 cm/min. Here are the pressures in 5-minute intervals:

• A the end of
  • 5 minutes, pressure = 5
    10 minutes, pressure = 6
    15 minutes, pressure = 7
    20 minutes, pressure = 8
    25 minutes, pressure = 9
    30 minutes, pressure = 10

The problem of being at 4-6 cm of pressure for extended periods of time kicks in when a newbie is told and encourage to keep hitting the ramp button whenever they feel uncomfortable. And every time you hit the ramp, the pressure goes back down to 4cm. So if, like kteague, you're waking up a lot (from another cause), and repeatedly hitting the ramp button, even before it's finished ramping up, then that can lead to a lot of time spent at pressures below 6cm.

Maybe some people would be better treated by a veterinarian,
who must deduct symptoms without language to confuse them.

I have WAY more respect and faith in my vet than I did in my (former) sleep doctor. Plus, my vet actually seems to care about his patients.

kteague wrote: Just keep in mind every minute you are asleep while the machine is in ramp time, you are un/underprotected from apnea events.

I agree that over use of the ramp feature can defeat the utility of CPAP. I use the ramp feature for 10 minutes because it allows me time to get my breathing rhythm in line with the machine. I thought I read that the machine will increase pressure if it detects an event requiring therapy during ramp. Is that incorrect?

kteague wrote:Every now and then I like to throw this out there for newbies who are using the ramp feature on their machines. Not fully understanding the implications in ramp use, my misuse was destructive to my sleep and nearly derailed my CPAP treatment. Ramp is a comfort feature for those who prefer it. Nothing wrong with using it if it's working for you. Just keep in mind every minute you are asleep while the machine is in ramp time, you are un/underprotected from apnea events. My early machine came set to a 45 minute ramp starting at a pressure of 4. (Later one came set for 30 minutes at 4.) My sleep deprivation was so extreme, I fell sound asleep before my head hit the pillow. Due to my struggle with limb movements and with feeling like I was suffocating, I woke every few minutes. The doctor and the tech at the DME had instructed me to just hit the ramp when I woke up. I didn't understand that this pretty much condemned me to spend most of my night at a pressure of 4 or just over that. My health took a nose dive after starting CPAP, and this was the main reason. Once I came here and and was advised to to shorten my ramp time and increase my ramp pressure, I began to turn around. I could keep the mask on for longer periods. My message is to use the ramp feature with knowledge and caution. If you think this may be a problem for you, do a little tally of how much time you sleep each night while under ramp. When I did that, it was an eye opener. I still use the ramp feature. It starts at a pressure of 9 for 5 minutes. Just long enough for me to settle in and get the coughing and throat clearing over and not be included in my data. Ok, off my soapbox for a few months. Just figure surely I'm not the only one with this experience.

+1

excellent advice. drag out that soapbox more often, especially if you've got more soap like that to sell!

On the virge wrote:

kteague wrote: Just keep in mind every minute you are asleep while the machine is in ramp time, you are un/underprotected from apnea events.

I agree that over use of the ramp feature can defeat the utility of CPAP. I use the ramp feature for 10 minutes because it allows me time to get my breathing rhythm in line with the machine. I thought I read that the machine will increase pressure if it detects an event requiring therapy during ramp. Is that incorrect?

While I personally don't use the ramp, I tried searching to find if treatment in the form of pressure adjustments took place during ramp time and could not find an answer. My assumption was that the machine would not react to or detect events during ramp time but I really don't know.

During my searching, I saw in the airsense 10 manual that it says:

You can set your Ramp Time to Off, 5 to 45 minutes or Auto. When Ramp Time is set to Auto, the device will detect when you have fallen asleep and then automatically rise to the prescribed treatment pressure

I wonder how it does this since we know that the machine has no way of knowing whether we are awake or asleep? Is it guessing based on breathing speed or pattern?

yaconsult wrote:I wonder how it does this since we know that the machine has no way of knowing whether we are awake or asleep? Is it guessing based on breathing speed or pattern?

or, does it? newer machines are smarter than older machines, AND the typical awake breathing pattern is different than the typical asleep breathing pattern.

if you zoom in on the flow waveform and look, one can often get a pretty good idea when the patient falls asleep and wakes up... one of the other mfgrs has a 'sensawake' that changes pressure based on breathing rhythm, that's pretty much what resmed is tinkering with there (as I call it) sensasleep autoramp feature.

yaconsult wrote: While I personally don't use the ramp, I tried searching to find if treatment in the form of pressure adjustments took place during ramp time and could not find an answer. My assumption was that the machine would not react to or detect events during ramp time but I really don't know.

The answer to that question is: It depends on what kind of machine you are using.

In general: If you are using a Resmed S9 APAP, the answer is no. The S9 AutoSet does not record events and does not respond to them during the ramp up period. The newer Resmed A10 APAPs, however, have an Auto Ramp setting; with the Auto Ramp, the machine tries to determine when you've fallen asleep, and at that point it will increase the pressure to the minimum pressure setting. I don't know how fast it increases the pressure setting and I don't know whether the machine leaves the pressure at the "beginning ramp" pressure the whole time the machine thinks you are awake. The way the A10 machine tries to determine that you've fallen asleep has to be based on analyzing the shape of the flow rate curve: Sleep breathing is much more regular and somewhat shallower than wake breathing. My guess is that as soon as the flow rate is sufficiently regular and there's a measurable decrease in how deep the inhalations are, the machine concludes that you are asleep and bumps the pressure up. It would be really useful to see some data posted by someone who is using an A10 with an Auto Ramp to see just what that machine does.

The PR System One machines (both Series 50 and 60) behave differently. If a System One APAP running in Auto mode detects and records the events during the ramp up period, it also responds appropriately to any events scored during the ramp up period. Meaning: If there are 2 or more OAs or Hs scored sufficiently close to each other, the machine bumps the pressure up by 1cm (and waits for a minute before responding to any additional events. If there is a Flow Limitation, VS Snoring event, or RERA scored, the machine bumps the pressure up by 1cm (and waits for a minute before responding to any additional events.) As soon as the pressure is increased, the machine continues ramping up from the new pressure setting.

yaconsult wrote:During my searching, I saw in the airsense 10 manual that it says:

You can set your Ramp Time to Off, 5 to 45 minutes or Auto. When Ramp Time is set to Auto, the device will detect when you have fallen asleep and then automatically rise to the prescribed treatment pressure

I wonder how it does this since we know that the machine has no way of knowing whether we are awake or asleep? Is it guessing based on breathing speed or pattern?

The only tool it has is looking at the respiratory pattern. It can be programmed to "know" what kind of respiratory changes are likely to happen when you actually fall asleep: Once you fall asleep, the breathing becomes much more regular (so the RR becomes less variable, as do the MV and TV numbers, and the shape of the inhalations in the Flow Rate graph become much more identical) and the breathing becomes more shallow (so the MV and TV both decrease as do the amplitude of the peaks in the Flow Rate graph.)

robysue wrote:I'd like to clarify an misconception here. If the ramp starts at 4cm and lasts for 30-45 minutes, you are NOT at 4cm the whole time. There is a linear increase in pressure from the time you turn the machine on to the end of the ramp period. Let's see what that looks like if your therapeutic pressure is set to 10cm (or your min pressure is 10cm if you are using an APAP) and you are using a 30 minute ramp from 4-10 cm: The pressure is increasing at .2 cm/min. Here are the pressures in 5-minute intervals:

• A the end of
  • 5 minutes, pressure = 5
    10 minutes, pressure = 6
    15 minutes, pressure = 7
    20 minutes, pressure = 8
    25 minutes, pressure = 9
    30 minutes, pressure = 10

The problem of being at 4-6 cm of pressure for extended periods of time kicks in when a newbie is told and encourage to keep hitting the ramp button whenever they feel uncomfortable. And every time you hit the ramp, the pressure goes back down to 4cm. So if, like kteague, you're waking up a lot (from another cause), and repeatedly hitting the ramp button, even before it's finished ramping up, then that can lead to a lot of time spent at pressures below 6cm.

THANK YOU Robysue for this information! I always wished I had the specifics. Saw something about it years ago but hadn't relocated it. I feel like I just found a treasure trove. My wakings were often every 1-2 minutes for hours on end. When I read that back I'm once again in awe that I even survived those times. Must be a tough old bird/broad. Do you know if all the machines share this pattern of increase? Just wondering if it is an industry standard or per manufacturer. Thanks again!

I never used Ramp. I think I had it set for maybe 10 minutes and a pressure a few centimeters below my set pressure when I set up my first machine, but never actually used it.


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