First Couple of Nights - ResMed AirSense 10 AutoSet

After a diagnosis of severe sleep apnea with an AHI of 37, I have been on a trial with a new F&P SleepStyle Auto CPAP. However, because this machine is not supported by SleepyHead, I have been kind of flying blind with it. I am not new to CPAPs and SleepyHead as my wife was diagnosed about three years ago with an AHI of about 77. She has a ResMed S9 which I monitor and adjust. She is doing very well with it, and had an AHI last night of 0.4. However for myself things are not going nearly so well. Over the two weeks with the SleepStyle AHI ranged from 2.2 to 8.8, and the sleep tech tells me I averaged 3.7. CA's are an issue. I traded machines with my wife for one night so I could look at my SleepyHead results. I set up my new A10 based on that one night. My first night of use gave me a 4.42 AHI. This was with an EPR of 3, so I reduced it to 2 for last night. A summary of the changes I got to night #2.

AHI: increased from 4.42 to 4.57 (yes, a small amount but in the wrong direction)
CA events: increased from 12 to 19 (wrong direction)
OA events: reduced from 16 to 14 (yes better from the higher EPAP pressure but not much better)
Total time in apnea: increased from 6:46 to 7:06 (not much but in wrong direction)

Now I am thinking that instead of making tiny baby steps and losing the impact of the change in the night to night noise, I should be more bold, and try and determine at least the direction I should head in. My thoughts are to try two fairly different set ups to see which one gives the better results, and then start to fine tune the better one. I was at a Max pressure of 10.6, min of 8.0, and EPR of 3. Now thinking of trying these two setups. One maximizes use of EPR and the other minimizes it.


#1 Minimize EPR
Max Pressure - 11 cm
Min Pressure - 8 cm
EPR - Off

#2 Maximize EPR
Max Pressure - 11 cm
Min Pressure - 10.5 cm
EPR - 3 cm

What do you think? I will try and attach the results from the last two nights.

I wouldn't make a lot of changes based on one or two nights. The difference in AHI between the 2 nights is negligible. Some nights my AHI is 0, some nights it is 0.5, some nights it is 1.2 (that's the last 3 nights). There was no difference in settings among the 3 nights. As you have noted, there is a random component involved - maybe I spent more time on my back the 3rd night, maybe something woke me up in the middle of the night and sleep wake junk inflated the AHI, maybe I spent more time in REM on the 3rd night. The point is the numbers will change from night to night without any change in settings. The important thing is to look at patterns over a longer period of time.

If this pattern keeps up, you might consider increasing your minimum pressure to a pressure just below your median pressure. But I wouldn't change anything yet.

Tried setup #2 last night, and it was a fail. I suspect I am opening at least my lips and letting air out especially at the higher pressures. That is being scored as a large leak, and I suspect also causing some of the apnea events. Will put the optimization project on hold until I sort out the leak issue.

Ron your=also hitting your max pressures a lot the machine needs some more headroom

Jas_williams wrote: ↑

Sat Apr 07, 2018 11:42 am

Ron your=also hitting your max pressures a lot the machine needs some more headroom

I think it is pushing pressure up trying to feed the air leak out of my mouth. I was barely reaching 10.5 or so before and I bumped it up to 11. Suspect when I fix leakage from the mouth the pressure will be OK. Seems to be a problem of "loose lips" that can't handle the higher pressures of this setup!

Ron AKA wrote: ↑

Sat Apr 07, 2018 1:23 pm

Jas_williams wrote: ↑

Sat Apr 07, 2018 11:42 am

Ron your=also hitting your max pressures a lot the machine needs some more headroom

I think it is pushing pressure up trying to feed the air leak out of my mouth.

No, auto machines *DO NOT RAISE PRESSURE IN RESPONSE TO LEAKS*

Point of fact, they will *LOWER* the pressure if the leak is bad enough, to try and get the mask to seal back up.

example:

palerider wrote: ↑

Sat Apr 07, 2018 2:10 pm

Ron AKA wrote: ↑

Sat Apr 07, 2018 1:23 pm

Jas_williams wrote: ↑

Sat Apr 07, 2018 11:42 am

Ron your=also hitting your max pressures a lot the machine needs some more headroom

I think it is pushing pressure up trying to feed the air leak out of my mouth.

No, auto machines *DO NOT RAISE PRESSURE IN RESPONSE TO LEAKS*
Point of fact, they will *LOWER* the pressure if the leak is bad enough, to try and get the mask to seal back up.

I probably rushed the explanation a bit. Here is a more complete story. When you have a mouth leak and an obstruction, the obstruction is beyond the point in the nasal passage that joins up with the mouth passage. So, with a blockage air shortcuts from the nasal passage and out the mouth. The air velocity goes up in the crossover point, and as a result of the Bernoulli principal, the pressure goes down locally. That probably makes the blockage worse, not better. And if the CPAP classes this as an obstruction it will try even harder to force the obstruction open. That is what can increase the pressure at the CPAP end of the pipe. At least that is what I am seeing in my results. Not sure how to explain your graph. Looks like the CPAP maxed out trying to feed the leak, while mine did not. If the CPAP fan/turbine reaches maximum flow then pressure will drop off.

Have you tried other masks?

A couple weeks ago, I used three different nasal masks...Eson2, Dreamwear cushion and the Wisp. Based on SH, the Wisp leaked the least for me....probably the Dreamwear the most. The mask changes were my only changes that week.

Dave

DavidY wrote: ↑

Sat Apr 07, 2018 5:29 pm

Have you tried other masks?
A couple weeks ago, I used three different nasal masks...Eson2, Dreamwear cushion and the Wisp. Based on SH, the Wisp leaked the least for me....probably the Dreamwear the most. The mask changes were my only changes that week.

This is the only mask I have tried. I've seen leaks before, but not like the leaks with this higher essentially fixed pressure. I woke up multiple times in the night with air blowing out my mouth. Not totally awake, but from the best I can remember, my teeth were together, but my lips were not up to the job of holding the higher pressure in. I don't think it is a mask problem, other than it's a nasal mask, and they can't do anything about mouth leaks. Now starting to look at full face masks like the classic Mirage Quattro. I'm going to try a chin strap and some medical tape on my mouth tonight to see what that does. If it does, I'm not sure that is going to be a long term solution.

A chin strap is cheap to try. As cheap as $10 on Amazon Canada.

Are you still able to trial test FFM? I am thinking about a FFM in case of colds and such. I have a nasal Pico mask on order....in my search for a near perfect nasal mask.

Dave

Ron AKA wrote: ↑

Sat Apr 07, 2018 4:55 pm

palerider wrote: ↑

Sat Apr 07, 2018 2:10 pm

Ron AKA wrote: ↑

Sat Apr 07, 2018 1:23 pm

Jas_williams wrote: ↑

Sat Apr 07, 2018 11:42 am

Ron your=also hitting your max pressures a lot the machine needs some more headroom

I think it is pushing pressure up trying to feed the air leak out of my mouth.

No, auto machines *DO NOT RAISE PRESSURE IN RESPONSE TO LEAKS*
Point of fact, they will *LOWER* the pressure if the leak is bad enough, to try and get the mask to seal back up.

I probably rushed the explanation a bit. Here is a more complete story. When you have a mouth leak and an obstruction, the obstruction is beyond the point in the nasal passage that joins up with the mouth passage. So, with a blockage air shortcuts from the nasal passage and out the mouth. The air velocity goes up in the crossover point, and as a result of the Bernoulli principal, the pressure goes down locally. That probably makes the blockage worse, not better. And if the CPAP classes this as an obstruction it will try even harder to force the obstruction open. That is what can increase the pressure at the CPAP end of the pipe. At least that is what I am seeing in my results.

No, That assumption is wrong.

Cpaps DO NOT "try ... to force the obstruction open"... never have, never will. There are modalities of obstructive apnea where more pressure from above will just block the airway harder, like pushing on a door that opens towards you.... therefore, *NO* cpap raises pressure *during* an apnea, they *all* raise pressure AFTER an obstructive apnea is over.

It is easy enough to mistake the cause/response behavior unless you've zoomed in on a breath by breath basis on the charts.

Ron AKA wrote: ↑

Sat Apr 07, 2018 4:55 pm

Not sure how to explain your graph. Looks like the CPAP maxed out trying to feed the leak, while mine did not. If the CPAP fan/turbine reaches maximum flow then pressure will drop off.

There's no explanation necessary, it's self evident. We've (the people that have been doing this for some years) have seen the same behavior in Resmeds and Respironics machines, when there's a bad enough leak, the machine lowers pressure.

Ron AKA wrote: ↑

Sat Apr 07, 2018 11:00 am

Tried setup #2 last night, and it was a fail. I suspect I am opening at least my lips and letting air out especially at the higher pressures.

Try taping your mouth shut with some surgical tape. I tapemine shut every night.

Please don't take post count as credibility, the two aren't the same. If someone needs to say how clever they are, they aren't.
If it were me. Turn off EPR if the CA scare you. min 10 max 20 and get a full face mask(f20?) I found it's easier to get use to, than playing with stuff that is a part fix. review in a month.
you may need to set the F&P a bit different to the resmed for your wife. the min on the F&P may need a bit more. both are good machines and I'd put it above the dreamstation on comparative test results.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005142/

Jas_williams wrote: ↑

Sat Apr 07, 2018 11:42 am

Ron your=also hitting your max pressures a lot the machine needs some more headroom

After last night's experience I agree with the need for more pressure now that the major leak issue has at least been temporarily solved. Not sure I can tolerate the quick fix solutions. Last night is showing some hope for improvement. I used a home made Tensor bandage chin strap and some Paper Medical tape on my mouth to eliminate loss of air through an open mouth. Large leaks were eliminated, and I think leakage rate is now acceptable, although I was fighting an issue with one nostril of the P10 not sealing well for the first half of the night. Not a lot of fun wearing all of this stuff and if that is what it takes I see a full face mask in my future.

As for results I got up in the night as the setup was not comfortable and I was going to abandon the tape on the mouth at minimum so I could get a better sleep. But the A10 told me the AHI was 0.7 so I put it all back on and tried a gain for the second half of the night. It was much worse with many of the events occurring in the last hour of sleep.

I think I will leave everything the same for tonight except for the max pressure. Especially in the second half of the night the demand for pressure was bumping into the 11 cm limit. This seems to be new as I was not needing that much pressure before. In any case it seems worthwhile to just put it at 15 cm and get it out of the way for now.

In general OA events are down, and CA events are up. In looking at the mask pressure detail I think the underlying issue is a waxing and waning of the breathing effort. Sometimes the cycle ends with an obstruction event and other times it ends with an open airway event. I suspect increasing the max pressure limit will probably prevent some of the OA events, but they will end with a CA event flag instead. So total events probably won't go down, just the ratio of the OA to CA.

If these OA events don't self correct over the next couple of months, I think I will also have to start checking out the AirCurve 10 options if I want to get AHI under 5 consistently.

Don't assume that it's the higher pressure causing unstable breathing that manifests itself as a central apnea.
It might also be post arousal central...you weren't totally asleep maybe because of an arousal from an apnea event or the airway trying to close off because the pressure couldn't hold it open.
Centrals might also simply be SWJ Sleep/Wake/Junk...tossing and turning and sighing and awake pauses in breathing getting flagged as centrals and they are real and if they aren't real they don't count no matter how many you have.

Remember these machines only measure air flow. They don't have a clue as to whether or not you are asleep and they are easily fooled by the irregularities of awake breathing.