ResMed Autoset 11 Settings Optimization

Hello all,

I'm reaching out to the community for some guidance on optimizing the settings on my ResMed Autoset 11 CPAP machine. I've recently been diagnosed with sleep apnea and I'm using it in APAP mode with the prescribed default settings of 4 min and 20 max pressure, no ramp setting. I'm also using the ResMed AirFit F20 full face mask.

While these default settings often give me good AHI results (< 1), I've been experiencing some unpleasant side effects. Specifically, I struggle with bloating, burping, gas, acid reflux, and abdominal pain from aerophagia. The pressure would go up to around 7 and it would be hard to exhale against it. I find it hard to exhale against the increased pressure. Additionally, when the pressure increases during sleep apnea events, it tends to wake me up, disrupting my sleep.

In an attempt to find a more comfortable solution, I tried using the EPR setting at level 3. This allowed me to sleep through the night without interruptions, which was a significant improvement. However, my AHI numbers took a hit, worsening compared to the default settings. I also felt tired throughout the day.

My goal is to find the optimal balance between comfort and effective treatment, minimizing the side effects while still achieving a satisfactory AHI. I would greatly appreciate any insights or recommendations from experienced CPAP users who have faced similar challenges.

Here are a few specific questions I have:

1) What pressure settings (minimum and maximum) would work well for managing aerophagia while still treating sleep apnea effectively?
2) What EPR level is beneficial for alleviating the discomfort of increased pressure during apnea events?
3) Are there any other settings or adjustments I should consider trying to improve my overall CPAP experience?

Here are the Oscar reports for my ongoing CPAP treatment:

3/29 Oscar report - 0.39 AHI from my first day using the machine with the default settings: https://imgur.com/CmQS5qY

3/30 Oscar report - 3.08 AH from changing it to EPR3: https://imgur.com/IEkwxk0

3/31 Oscar report: 0.31 AHI on default settings: https://imgur.com/rivFRtZ

4/1 Oscar report: 4.16 AHI on default settings https://imgur.com/naFJaXw

Welcome! In so many ways, you're off to a great start. You're sleeping with the machine, you have leaks under control, you're using Oscar, and you're taking an active role in making your PAP therapy work.

Sleep is highly variable from one night to the next, so when you make changes to your settings, you'll want to give them multiple nights before you try to assess them, unless they're a disaster. Case in point: on the 31st, you had a bunch of CAs after your first cluster of OAs. During the CA period, I'm willing to be you were awake, experiencing arousal breathing, or experiencing unstable breathing kicked off by the first post-arousal CA. In other words, you should mentally subtract those CAs from your AHI, since they probably didn't occur during sound sleep.

Another case in point: on the 31st, you had two little OA clusters. These may well have resulted from your sleep position. Perhaps you rolled onto your back, or perhaps you tucked your chin down toward your chest. Apparently you didn't do anything on the 30th to prompt OA clusters.

All that said, I would recommend that you stick with EPR of 3 and raise your minimum to 7. That might sound counterintuitive, given all the trouble you're having with aerophagia. But it may well help to head off obstruction and some of the pressure increases you're seeing.

Also, with a minimum of 7, you'll have the advantages of your full EPR throughout the night. (The lowest the machine can go is 4, so if your pressure is, say, 5, you can only get EPR of 1.) EPR may have some value to you not just for comfort but for reducing flow limitations.

If you're using several pillows, or a high pillow, you might want to consider using a single, fairly low and firm pillow, which might minimize your chances of positional OA issues.

After a few nights with your minimum at 7, you can consider whether it would be helpful to cap your pressure to avoid aerophagia. Sometimes there's a trade-off between AHI and aerophagia, but with just a little luck, you'll find a good sweet spot.

Keep us posted, would you?

Thanks for the helpful analysis. Since you mentioned changes taking multiple nights in order to adjust, do you recommend staying at the current 4 min pressure with 3 EPR for 2-3 days before going to 7 min with 3 EPR? Or should I just try out 7 min and 3 EPR at the soonest chance?

As for capping the maximum pressure, is that required if the pressure never goes all the way to 20?

I’d suggest you go ahead with the increase to 7 as your minimum. We can then take that as a starting point for any further adjustments.

Occasionally it will make sense to cap pressure below where it “wants” to go, if it’s mostly being driven up by flow limitations and if pressure increases are problematic for one reason or another. Let’s see how things go, though, before considering that.

Thanks for the suggestion and clarification. Before I share the results of last night's sleep report, here is some further context that I forgot to add. On 3/31, my AHI was low using the default settings (0.31). The next night on 4/1, it got considerably worse AHI (4.16), and this day was when I started experiencing GERD/Acid reflux symptoms from the increased pressure, and this lasted throughout the entire day. The only thing I changed on 4/1 was the humidity setting from 3 to 4, and tried out a new pillow which I stopped using after this result and went back to my old pillow.

3/31 Oscar report: https://imgur.com/rivFRtZ

4/1 Oscar report: https://imgur.com/naFJaXw

With that being said, here is the Oscar sleep report for last night 4/2: https://imgur.com/NJl9uPG

For 4/2, I changed the min pressure from 4 to 7 with EPR 3. The pressure felt a bit more forceful than usual, the mask was pulsing upon each breath, and I found it hard to adjust my breathing to the faster frequency of the machine, but I managed to fall asleep. I typically sleep on my side (left). I woke up around 5:00 due to bloating and burping while the pressure was around 14. I tried to fall back asleep and then at 7:00 I was woken up by excessive stomach pain from bloating (I had a CPAP belly). I have some GERD/reflux still.

I am not sure if this means the min inhale pressure of 7 is too much. It gave me a better AHI than when I had EPR 3 on 4 min pressure, but the abdominal pain was alarming.

anker9000 wrote: ↑

Wed Apr 03, 2024 12:05 pm

woke up around 5:00 due to bloating and burping while the pressure was around 14. I

anker9000 wrote: ↑

Wed Apr 03, 2024 12:05 pm

I am not sure if this means the min inhale pressure of 7 is too much.

Cross your fingers that it was the pressure pushing 14 that was feeding the aerophagia monster and not the 7 cm minimum because you need the minimum for the OAs and hyponeas.

If it were me....I would limit the maximum to 10 and see if that stops the aerophagia issues or not.

I went through this exercise a little over a year ago. The one graph that help me the most was the time at pressure graph ( normally at the very bottom of the graphs). I looked at where I was spending most of my time and I noticed that when I went below there my AHI increased. So I set my min just barely below where I was spending most of my time at pressure. I was normally between 11 & 13 so I set my min at 10 with an EPR of 3. My events went to zero most nights. My 1 years average is .36 AHI. It is unusual for any night to be above 1. This may or may not work for you, I had the Resemd AS11 on full auto 4-20 for a week and then looked at each night. The time at pressure graph worked great for me.

Pugsy wrote: ↑

Wed Apr 03, 2024 12:45 pm

Cross your fingers that it was the pressure pushing 14 that was feeding the aerophagia monster and not the 7 cm minimum because you need the minimum for the OAs and hyponeas.

If it were me....I would limit the maximum to 10 and see if that stops the aerophagia issues or not.

I will try capping max pressure at 10 to see if it prevents the painful aerophagia. As for EPR 3 requiring 7 min pressure I was under the impression that if it was set to min 4 pressure with EPR 3 it would activate once the pressure starts increasing upwards, so that was why I left it at 4 since 7 felt like a lot. I didn’t know it had to be set at 7 for EPR 3 to kick in (I thought it just came on whenever you pass the threshold of 7).

As for the time at pressure graph, most of my time was spent at around 4-5 min pressure when it was on the default. The newest setting of 7 min shows mostly 7. But this information is useful to know, thank you.

I was also wondering - is turning on auto ramp recommended at all? I read it can cause people to wake up or not get enough air. I had mine turned off since starting at 4 pressure was easy to adjust to. 7 was a bit harder though.

anker9000 wrote: ↑

Wed Apr 03, 2024 6:03 pm

I was under the impression that if it was set to min 4 pressure with EPR 3 it would activate once the pressure starts increasing upwards,

The machine can't ever go below 4 cm even with EPR set to 3.
You have to be using 7 cm to get the FULL benefit of EPR but you still get a little reduction as the machine increases the pressure.
Like when the pressure reaches 5 then you are getting a drop down to 4 cm (even if it is set to 3 epr) so a 1 cm drop.
or when the pressure reaches 6 then you get a drop down to 4 so a 2 cm drop.

If 7 is a problem for you...drop it to 6 or 5 or go back to 4. Sleep is your primary goal.....without sleep none of the other data really means all that much does it?

EPR helps reduce flow limitations though...and FLs are a big driving force for increasing the pressure so using EPR will often lessen the pressures the machine wants to go to.

BTW.....just because someone else out there in the world using cpap has a problem with "auto ramp"....that doesn't mean that everyone else in the rest of the world will have the same problem.

Don't assume that you will have the same problem with anything.

And I am not a big fan of auto ramp but not for the reason you gave.

Pugsy wrote: ↑

Wed Apr 03, 2024 6:54 pm

If 7 is a problem for you...drop it to 6 or 5 or go back to 4. Sleep is your primary goal.....without sleep none of the other data really means all that much does it?

EPR helps reduce flow limitations though...and FLs are a big driving force for increasing the pressure so using EPR will often lessen the pressures the machine wants to go to.

Thanks for clarification on EPR and ramp. During the first few days of using default settings I’d occasionally wake up due to burping / air bubbling when the pressure was around 7, so that is why I wasn’t sure if 7 was good. I was diagnosed with a mild case of sleep apnea (AHI was 7, though I didn’t sleep well at the lab), so I don’t know if I would require a lot of pressure. So I am wondering if I should try going back to 4 and cap it at 10 or something, with or without EPR3 enabled, since the median pressure stayed around 4-5 in the initial period.

And yeah, sleep is definitely the primary goal, well, that and eliminating the aerophagia. I just need to find the appropriate standard settings first that works in order to adjust them later. I am also going to use a chin strap because I find that my mouth opens when I sleep (due to drool in the mask), so that may help with the bloating.

anker9000 wrote: ↑

Wed Apr 03, 2024 8:57 pm

So I am wondering if I should try going back to 4 and cap it at 10 or something,

Sleep...primary goal....aerophagia messes with sleep and that's bad news.
What we have to try to figure out it settings that do a decent job preventing your airway collapses AND don't open the door for the aerophagia monster to sneak in and mess with your sleep and how your belly feels.

Right now we don't know what pressure is causing the aerophagia.....is it 12 or 13 or 14 or 10 or 7 or anywhere in between?
We don't know until we try something.
EPR is the first thing that is added to therapy when someone is complaining about aerophagia.
I know someone who gets bad, bad aerophagia pain with 6 cm pressure....yep...6.

First we find a pressure that doesn't make the belly mad...then we have to decide if that pressure is doing a good job keeping the airway open or do we need more. Sometimes we have to make compromises and we may have to do that with you.

And...you might end up doing better (aerophagia wise) not using auto adjusting pressures. Fixed pressure.

Pugsy wrote: ↑

Wed Apr 03, 2024 9:11 pm

Sleep...primary goal....aerophagia messes with sleep and that's bad news.
What we have to try to figure out it settings that do a decent job preventing your airway collapses AND don't open the door for the aerophagia monster to sneak in and mess with your sleep and how your belly feels.

Right now we don't know what pressure is causing the aerophagia.....is it 12 or 13 or 14 or 10 or 7 or anywhere in between?
We don't know until we try something.
EPR is the first thing that is added to therapy when someone is complaining about aerophagia.
I know someone who gets bad, bad aerophagia pain with 6 cm pressure....yep...6.

That’s an important insight that I wasn’t aware of, especially when you mention the pressure going down to 7 - I may try making it go 4 min 7 max based off the 3/29 and 3/31 results since that’s where the median and max pressure values are around, and those dates also had good AHI. Starting small first may be better as you mentioned that someone with 6 pressure could even feel aerophagia. And yeah compromises and finding the middle ground between keeping the airway open and the aerophagia at bay is what is fine, it doesn’t need to be the best but what works.

4/3 Oscar Report: https://imgur.com/yzkOcgc

4/3's sleep wasn't that great as I kept waking up due to burping/air bubbles, and I still have acid reflux symptoms. However, I got a better AHI score than the past few days (0.69).

For last night I wore a chin strap, changed the min pressure to 4 and capped the max at 7, and turned off EPR 3. I think the lower level pressures help a lot. I slept on my left side. I didn't experience the extremely painful bloating like yesterday, it was instead a slight pain in the morning at 7:00. This may need more testing but when I sleep on my side I experienced more aerophagia than if I were to sleep on my back. Which is odd since typically it's the other way around.

Well that's encouraging! Stick with these settings for a few more nights and see how it goes. The next step I would probably recommend is to re-introduce some EPR. That will give you a lower pressure when you exhale (except when you're at 4), which might help with the residual aerophagia issues.