Ok, Ready to start.. any suggestion?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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Blackhilt
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Ok, Ready to start.. any suggestion?

Post by Blackhilt » Fri Feb 09, 2018 10:25 am

Going through CIGNA with a 750 Deductible was a no go. I went hunting online and found a brand new Dreamstation APAP with heated tube, 2 extra regular tubes, Dreamwear Mask kit and a bottle of Distilled water for $639 shipped 2day FedEx. I wanted the RESMED but the prices were much higher. I'm siting in my living room looking out the window waiting for the delivery as I type this. The Doctor sent me my Home Sleep test results and the details are as follows:

Study time 6 hr 47 min
23 obstructive Apneas
0 mixed Apneas
2 Centrals Apneas
107 Hypopneas
AHI of 19.5
197 snoring events

Pulse Oxi Average Ox Saturation was 96% ODI was 6.4% lowest was 88. ZERO time spent below 90%

Average Heart Rate 63 bpm

The Doc called it MODERATE.
RX for the APAP was 4 min 18 Max

I downloaded Sleepyhead for my pc and am ready to use it after I collect some data. After some reading I was thinking of raising the min to a 6 (what do you think?) turning auto-on ON , auto-off OFF (to avoid accidental turning off in case of a big leak. I was thinking keeping ADAPTIVE humidification on, as well as keeping Smart Ramp ON. The FLEX A & C options are a little confusing, any suggestion there?

Glad to hear your expert opinions. Thanks for taking the time to read.

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ChicagoGranny
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Re: Ok, Ready to start.. any suggestion?

Post by ChicagoGranny » Fri Feb 09, 2018 10:29 am

Sounds like a good plan. I would turn Flex off. You can always add it later if necessary. (I find it annoying and have no problem exhaling against pressures as high as 20.)

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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Fri Feb 09, 2018 10:48 am

I think your plan and starting point on the settings is a great place to start. You gotta start somewhere.
I agree that the 4 minimum starting minimum is likely going to be uncomfortable (not to mention maybe suboptimal if you need pressures in the double digits) and the 6 minimum is a better starting point.

Bear in mind that it is the minimum pressure that is the most critical setting...not so much the maximum.
The minimum has to be close enough to where you need to be to hold the airway open that the machine can get to that pressure in a timely manner. These machines don't go from 4 to 10 in the blink of an eye...instead they go up taking several minutes to get there and they come back down just as slowly.

My first machine was the older version of what you got....it will work well for you. Yeah, I know the ResMed might be a little more preferred by some people but it's not like the Respironics is a crap machine. It just works a little bit differently than the ResMed so the path it takes is a little different but the end goal is the same and it gets there.
And yes...I understand that the cost difference can be a big factor and it's not like you settled on a low quality basic machine from a China. We get what we can comfortably afford. No need to feel bad about your choice...it's a good machine.

Flex is the exhale relief. My suggestion is to try both CFlex and AFlex and each setting offered 1, 2 or 3 and even off.
Pick the setting that simply feels more natural to you. Play with them while awake. There is even a Demo available so that you can quickly try them at your minimum of 6 (BTW...you need the minimum of 6 for Flex to even kick in...it doesn't engage below 6 anyway).
I liked AFlex at 2...was just more natural feeling...kinda like I wasn't even using a machine but you might prefer a different setting due to the way you breathe. Flex relief is based on your own air flow or how forcefully you breathe...it sort of auto adjusts to you own particular breathing rhythm. It doesn't work the same way with the reduction as the ResMed EPR exhale relief works.
There is a drop with Flex but not always a per cm drop and the timing of the reduction is a bit different.
It's that timing thing that you need to see what seems to match your own breathing pattern and why you will just have to try all the settings and then settle on which one that simply feels better to you.

For me...the AFlex at 2 seemed to match my own breathing really well..when I tried 3 I felt like the machine was rushing me a little...sort of like it was making me hyper ventilate a bit....the setting of 1 seemed like it was a bit slow and not wanting to keep up with my own rhythm. AFlex is supposedly a little "smoother" in the transition from exhale to inhale and back again.
To be honest I never really cared for any CFlex setting...it was AFlex that won me over but you might like CFlex way of doing things.

I know you will want to test things out when you get the machine and long before bedtime. Use that time to play with Flex and see which one you like.
I assume you already have the clinical/provider manual (has more information in it than the user manual) but here's a link where you can request the manual via email just in case you don't already have it or someone else wants it.
It is a combo manual...meaning it covers DreamStation CPAP, Pro and the Auto CPAP models.
https://www.apneaboard.com/adjust-cpap- ... tup-manual

Finally come back this afternoon if you run into something you don't understand.

Oh...that auto on thing....sometimes a person has to breathe deeply for 2 or 3 breaths for it to kick on..so don't panic if it doesn't kick on with the first breath. It depends on pressure used, mask used and simply how deeply you breath and sometimes one of those factors can cause it to be a bit slow in response. It always too me 2 or 3 big deep breaths with my nasal pillow mask before it would kick on. If it becomes to stressful...just reach over and push the button.

About the ramp...I wouldn't use it at all with the minimum of 6 you are going to be using. It will start at 4 and go to 6 and that 4 might not be comfortable (might feel rather stifled) and you really should be able to handle 6 fairly easily...and remember Flex won't work until you are at 6 anyway.
Now later on if it is determined that your minimum pressure needs to be a lot higher for some reason and that higher starting point is uncomfortable we can talk about using the ramp to help you out.
But with the minimum at 6...I wouldn't even engage ramp.
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Re: Ok, Ready to start.. any suggestion?

Post by LSAT » Fri Feb 09, 2018 11:24 am

If you wanted ResMed, you could have gone here...but, no distilled water....
https://www.amazon.com/Res-Med-AirSense ... ns&keyword

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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Fri Feb 09, 2018 11:47 am

LSAT wrote:If you wanted ResMed, you could have gone here...but, no distilled water....
https://www.amazon.com/Res-Med-AirSense ... ns&keyword
A little bit late now for the OP here but anyone else thinking of going this way...don't dally long.
I have been watching Amazon and this is the lowest price I have seen in a while...as we all know..prices can and will vary quite a bit sometimes.
I know...having had something sit in my cart that I should have put the hammer down on and find it 4 days later at twice the price because of supply and demand and price changing.

I am afraid the days of the $500 AirSense 10 AutoSet for Her price are in the past. But you never know...so anyone in the market...just watch and be prepared to put the hammer down if you spot a good price you can afford for any of these machines or products.
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Re: Ok, Ready to start.. any suggestion?

Post by Blackhilt » Fri Feb 09, 2018 11:53 am

Thanks for the rapid replies. Also many Thanks for the detailed Analysis Pugsy and perspective! I have read how you recommend a tighter min max range and will be getting some data to come back for your thoughts. I cant wait to try it out. Headed now for the clinical manual link, thanks. LSAT, yes, I saw that unit on AMAZON, your right, no water bottle , no extra tubes and no mask and I ALMOST picked it, but the seller did not "feel" right when I read their policies and some of the negative feedback (not too many honestly, but I want to feel like the seller knows what their doing, like their dedicated to home healthcare). The seller I bought from has a brick and mortar with TONS of google reviews that gave me the confidence I needed.

From what I've read on here shared by the many experienced users,I may, in two or three years, pick up he Resmed and have the Philips as a backup or dedicated travel unit. I've perceived that Therapy so important that depending on just ONE of any part of our devices is not wise. What a great resource this place is.

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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Fri Feb 09, 2018 12:21 pm

You may or may not end up really needing a "tighter" range.
I almost always tighten things up with more minimum though and don't worry so much about the maximum unless someone is hitting it for prolonged periods of the night.

Myself...7 minimum (and I like EPR and I use a ResMed at 3 because I really like how it feels) and 20 max...fairly wide open. Works well for my needs...may or may not work well for someone else but we have to start somewhere don't we?
I sleep through all the pressure changes (if I didn't I would rein it in a bit)...and leaks aren't an issue when it goes higher...and it rarely stays higher (I sometimes hit 15 or more) for very long.

When I was using Respironics auto...I had to use 10 minimum (and again the 20 max) to get the same results I now get with the ResMed...you may or may not end up in a similar situation and you may or may not move the "getting of the ResMed auto" up on your to do list.
Let's cross that bridge if and when we come to it.
FWIW...I was quite happy with the Respironics for many years and the only reason I changed was just because I wanted to try something new and I could do it easily and cheaply. I Iike trying new stuff...new machines...new masks...new anything.
Helps with the cpap boredom that comes from using this stuff for coming on 9 years now. Besides...someone has to try this new stuff out and it might as well be someone who likes to try new stuff.

We will know pretty quickly if there is an urgent need to alter your starting settings. Not a big deal.
Your main job right now is getting comfortable with the setup and actually getting good solid sleep so that the data can be evaluated better. It's really hard to evaluate no sleep.
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Re: Ok, Ready to start.. any suggestion?

Post by scruffies » Fri Feb 09, 2018 2:02 pm

Welcome to this incredible forum!

I assume you already have the clinical/provider manual (has more information in it than the user manual)
I have the Airsense 10 Autoset. Anyone know of a link to download the clinical manual for that machine?

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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Fri Feb 09, 2018 2:04 pm

scruffies wrote:I have the Airsense 10 Autoset. Anyone know of a link to download the clinical manual for that machine?
It can be requested from the above link (they have a big long list of manuals available via email) but this one I happen to have a direct link for it and you can save some time
Again it's a combo manual...but it's all that ResMed offers clinicians and providers.

https://sleep.tnet.com/home/files/resme ... -guide.pdf
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Re: Ok, Ready to start.. any suggestion?

Post by scruffies » Fri Feb 09, 2018 2:22 pm

Thanks so much Pugsy.... :D *deep bow to Pugsy*

Now that I've crossed over to the Dark Side and have a little knowledge I am REALLY dangerous!

Going to be interesting to see how my sleep doc takes my fiddling with the machine.

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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Fri Feb 09, 2018 2:39 pm

scruffies wrote: Going to be interesting to see how my sleep doc takes my fiddling with the machine.
Some won't care...some are mildly annoyed when they realize that we realize they aren't God...some really get their panties all in a wad and become someone I wouldn't care to do business with.

When I went back to see my doctor for my follow up (and the only time I have been back some 8 years ago) I politely showed them what I did and explained why and they were good with it and I got a big pat on the back and "seems like you know what you are doing, come back if you run into trouble you can't handle" and that's the last I saw of them back in Aug of 2009. Haven't run into anything I can't handle. Just as well I got the pat on the back thing because if they had given me any grief they would be taken out of the list of people who I would see for anything. I have worked with so many doctors over the years that I long ago realized they didn't walk on water and there was another one around the corner to take their place if I didn't like someone for any reason.

I think most doctors are probably okay with changing things (or they should be) if the change was based on fact and results and with education. Blindly changing something for no good reason other than they can...not a good idea IMHO no matter who is doing the changing.
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Re: Ok, Ready to start.. any suggestion?

Post by Blackhilt » Mon Feb 12, 2018 9:44 am

The Dreamstation finally arrived. I must say it is bigger in person. The Provider sent me a DReamwear mask with all the pillows as well as the under the nose attachments. The pillows didn't work for me, I'm using the under the nose piece. Its a design that works well for me as I sleep with a closed mouth.

I am HIGHLY motivated to use this device and set it up right away. What I DID learn was that its no walk in the park to get accustomed to it. In Miami the weather is HOT so we live under constant AC. I didn't realize how used to sleeping with the cold AC air I was. The air from the CPAP felt warm and muggy and the new breathing was suffocating. I experienced anxiety thinking I was going to suffocate as I exhaled and felt I could not inhale fast enough. I followed all the "ease into it" pieces of advice I've read and gradually fell asleep. When the machine hit 14 about an hour or two I woke up and tore the mask off my face. I felt frustrated and scared, something I had only read about. I wasn't expecting that feeling of smothering. The next day I put it on for a short nap and talked myself down from my anxiety mountain. At night I tried it on again was able to get 6 hours. The next day another short nap followed by 8 hours and last night I got 7 (had to get up for work). Although I did have some anxiety before going to bed thinking about the therapy my body and mind have been getting used to the night of PAP. I told myself I have to not worry so much about AHI, min max and hours and just work on getting used to the new normal. That kind of took the pressure off and I have been having a much better almost pleasant experience. I have also been able to ignore the "staleish" air temp.I fully respect and empathize with all who struggle to get acclimated to CPAP/APAP. It's no joke, and the advertising pictures do make it look easy, but it can be challenging. I am waking up without headaches and that helps me stick with it. Support group you ask? YES, super important. I have my Wifey who keeps tellign me how much better I look and she's proud , etc, etc. Also reading the many experiences here and the encouragement given is super important.

Now on to the technical stuffs

My AHI for the sleep test was a 19.
My first session of therapy was a 14 AHI with zero leaks and min 6 max 18 (bummed me out a bit, I thought I was gonna get at most a 5)
the machine reported a 90% of 11cm but maxed at 14.5cm

The AHI has now gone down to 9 (after 3 days)
I raised my start pressure to 7 (and actually prefer it over 6. 4 is just too low)
I dont ramp as I fall asleep pretty quick and feel the 30 min of ramp is too long.
Heating the tube to 1 and max on humidity (otherwise I get congested)
lowered the CFlex to 2

I want to get more comfortable with the therapy and add some more days of data before I start hitting the sleepy head and uploading for tweaking advice.

Do you guys clean your humidifier tray EVERY day?? Thanks for the help and support.

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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Mon Feb 12, 2018 10:24 am

Blackhilt wrote:Do you guys clean your humidifier tray EVERY day??
I don't. :lol: :lol:
When I first started therapy I dumped it every day and let it dry but that got old real fast. Didn't take me long to adopt a more relaxed cleaning and maintenance schedule.
Now I do use distilled water because I am on well water and in an area with high mineral content.
So this is what I do...you can choose to do whatever YOU are comfortable doing.

When I do end up using well water (ran out of distilled for whatever reason) I will dump the water chamber each morning.
Mainly to lessen the chance of mineral build up because of my hard water.
I don't clean it though...don't wash it when I dump it. Just dump it and let it air dry.

When using distilled water I might dump and clean (wash with soap and water) once every month or two whenever I happen to think about it.

The distilled water advice...that's for preventing the mineral build up that can happen when the water contains a lot of minerals.
And more from a yuck factor than anything else...a little mineral build up doesn't do anything but look a bit ugly.
Won't hurt you or your equipment.
If you live in an area where the water doesn't have much of a mineral content it and you can drink the water...you can use it in the humidifier. Your choice.

If worst comes to worst and a person does get some mineral build up in the water chamber.
It's easily removed with a little vinegar soak followed by a good rinse to get rid of the smell if you don't like the odor of vinegar (which I hate the smell).

So you have lots of room to adapt your cleaning routine to whatever you feel comfortable doing. When I was new to therapy I had a really rigid strict routine but that got old real fast. I am okay with my less rigid schedule now. You have to figure out what gives you peace of mind and the great thing about it....you can change it anytime you wish.

For the higher AHI that you are seeing right now I wouldn't worry so much about it right now especially since you are reporting having trouble falling asleep. I suspect some of your AHI might be awake breathing irregularities getting flagged and elevating the AHI.
But do go ahead and post your SleepyHead detailed reports so we can see when those flagged events are happening and thus maybe be able to ease your mind about the AHI thing.
I once had a guy with AHI of 20 on the machine and he was worried sick about it. Once we looked at the report and did some discussion about awake event flags (he was having some insomnia issues as well) and it was determined that the bulk of that AHI was awake events (we call them SWJ or sleep/wake/junk) and re calculated the AHI for just the asleep time...it was only 1.8.
And once he got that worry set aside he was finally able to go to sleep easier and faster and the AHI eventually came down to a nice low number without having to re calculate it because he was actually sleeping a lot better and much less SWJ flagging.

Do remember that these machines don't have a clue if you are awake or asleep...they just measure air flow and that includes awake air flow where it is very common to have irregularities and pauses in breathing that can confuse the machine.

90% numbers...it's not where you were at for 90% of the night.
The definition is....at OR BELOW for 90% of the night. People often don't know about or remember the "or below" part of the definition. 90% numbers are easily skewed upwards by a relatively short period of time at higher numbers so they may or may not be all that useful or important.
I prefer to use Sleepyhead and follow the median average as more of an indicator where I might spend the bulk of the night.
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Re: Ok, Ready to start.. any suggestion?

Post by Pugsy » Mon Feb 12, 2018 10:35 am

Oh...if using SleepyHead you might find SH telling you that with the DreamStation you are having massive large leaks and you don't see any large leak flags on the Events graph.
That's because SH is using a ResMed large leak red line number and Respironics machines need to use a different number but SH defaults to that ResMed leak red line.

So don't immediately go into panic mode about leaks if SH says you are having them...we just need to reset SH so that it takes into account a Respironics red line.
Preferences/ CPAP tab...on the right side change the 24 L/min red line threshold to something more suitable for a Respironics machine.
Unfortunately Respironics doesn't give us a static single number as a red line because it actually varies depending on pressure and mask used but if you change it to around 60 L/min..it's going to be a nice conservative red line number. In reality your red line might be 80 or 90 L/min but we have no way to know for sure.
Final evaluation...look over on the Events graph and see that LL at the top...that's large leak and it's what your machine reports and not a SleepyHead calculation. If you don't see any LL flagged areas..you didn't have any large leaks no matter what the SH statistics might say.
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Re: Ok, Ready to start.. any suggestion?

Post by chunkyfrog » Mon Feb 12, 2018 10:40 am

I use a similar policy with tank maintenance, but I take a good look inside before topping it off.
If anything looks amiss, I can rinse or wash, depending on what it needs.
Since it is right before bedtime, drying is not necessary.

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