2nd nite New Auto, Lots of Leaks, AHI's, Questions

[azmanatheart]

I changed my profile to show my new RemStar AutoM Series Model 510M w/Heated Humidification.
It is so much more comforatable than the Resmed S7 I had for 2 years, especially at my higher titrated pressure of 16.
My wife described to me this morning the nighttime symphony of new sounds with which I serenaded her last nite: sqeeks, sqeels, rushing air, farts, mask farts, etc.. I slept obliviously well. I don't yet have the software, but I broke into the Clinicians screen and here is the data for 2 days of usage. I could really use some help interpreting what it means;

RemStar V5.52
Sessions - 2
Therapy Hours 14.9
AHI 7 DAY AVG 36.3
System Leak 40.1 L/Min
90% Pressure 16.0 m/h20
Therapy Mode AUTO
Comfort Type A-flex
A Flex Setting 3
Min Press- 7
Max Press- 16
Ramp Press 5 15 minutes

I'm using the Mirage Quatro Full Face Mask, medium size, and it is the best fit I can seem to get with a full face mask. I had it tightened down a lot to keep the leaks to a minimum while using the ResMed S7, and I started using a strip of moleskin on the bridge of my nose to prevent the pressure sores. Part of my issue with getting a good seal (I think) is the shape of my face, which is narrow. My eyes are a little closer together than 'normal', the bridge of my nose is relatively high, and my cheeks flare back. The small mask is too small, comes too close to my lower lip, and the medium leaks around the cheeks unless I tighten it way down. Unless there is a custom mask, or I remold my mask with a heat gun, I may have to make the most out of this fit. I do have a Comfort Gel mask on order, they were out of stock of mediums when I got the ResMed Auto M Cpap with A-flex.

I cannot find the normal leak rate for the Quatro, so I don't know if the system leak is high or not, and I don't know how this effects the AHI.

Can anyone help interpret this info and make some sense for me? Before my wife unPLUGS my machine too!
Thanks,
Jeff

[RipVW]

That AHI = 36 is VERY high--goal is 5 or less. And your range between lower and upper pressure settings is pretty wide. I think a more typical range is around 5 (e.g. 11 and 16 rather than 7 and 16).

[azmanatheart]

That AHI = 36 is VERY high--goal is 5 or less. And your range between lower and upper pressure settings is pretty wide. I think a more typical range is around 5 (e.g. 11 and 16 rather than 7 and 16).

Yes, the range is very high. The reason- my titration study showed that my apneas finally subsided at 16m (in supine position), but it also showed that I had no apneas at all while sleeing on my side at 10, and then again at 12. So I was hoping that the Auto could find the best pressure for those different positions so that I didn't have to be at a permenent 16. With the leaks and the 90% pressure being 16m, I'm not able to answer that question.

Is the AHI number reliable with that much leakage?

Thanks,
Jeff

[RipVW]

Is the AHI number reliable with that much leakage?

I doubt it is 100% accurate/reliable, but I don't think it would be way off either. I'll defer to some of our old timer experts on the forum to answer that.

[Wulfman]

Without the software and card reader, using an Auto in a range of pressures is like flying blind.

My advice is to always start off with your titrated pressure settings (CPAP mode) to get a reference point or baseline numbers.....then, adjust from there.


Den

[bdp522]

Here is where to find the chart for leaks;
http://www.resmed.com/en-us/products/se ... _multi.pdf

Using this chart, your leaks are not bad. Your problem is most likely too wide a range. It can take a long time for the machine to reach a pressure of 16 when it starts at 7. You need at least a 10 when on your side so why start at 7? For now I would start with a range of 10-16 and see how that goes. If need be keep creeping up the lower pressure. If it were me I'd go to 12-16 and see what happened.
You may also see if you could use a lower a-flex setting. Some don't do well with a-flex(or c-flex) and you need to try the different settings to see which will work better for you.
Remember to change just 1 thing at a time so you know which changes are helping and which aren't!

Brenda

[ozij]

Use Mack's silicone ear plugs (used by swimmers) to make the mask stick to your face better. Roll the silicone into a snake and put it between mask and face.

[Sleeptech010110]

Most masks are built with a leak around 20, to allow CO2 to be blown off. Clinically speaking, leak of 40 is where it's considered to begin to lose effectiveness. Below 40 isn't any big deal.

Masks are designed to fit comfortably, with a semi-loose fit. Try adjusting the nose bridge around before tightening it, sometimes too tight causes just as much leak as too loose.

PAP units change pressures almost instantly, so the range from 7-16 would be barely less than half a breath. That is, IF it were a BI/PAP machine.
BI/level pressures are set during testing, the lower number is what you need to exhale with little effort, the higher is what prevents apneas.
IF it's a AUTO unit, which is what the therapy mode suggests, then you might have a complex form of apnea, which means it starts at seven and goes up until your apnea is cleared.

Either way, your settings are a prescription written by your doctor, please check with your medical supplier or the clinical director of your sleep facility before trying to adjust your settings. Those were determined by your overnight Titration study to be the settings you needed to most effectively eliminate your apnea's.

If you do decide to try and adjust your pressures, please be careful. Your health is the one thing you don't want to take chances with, obviously.

[Wulfman]

Most masks are built with a leak around 20, to allow CO2 to be blown off. Clinically speaking, leak of 40 is where it's considered to begin to lose effectiveness. Below 40 isn't any big deal.

Masks are designed to fit comfortably, with a semi-loose fit. Try adjusting the nose bridge around before tightening it, sometimes too tight causes just as much leak as too loose.

PAP units change pressures almost instantly, so the range from 7-16 would be barely less than half a breath. That is, IF it were a BI/PAP machine.
BI/level pressures are set during testing, the lower number is what you need to exhale with little effort, the higher is what prevents apneas.
IF it's a AUTO unit, which is what the therapy mode suggests, then you might have a complex form of apnea, which means it starts at seven and goes up until your apnea is cleared.

Either way, your settings are a prescription written by your doctor, please check with your medical supplier or the clinical director of your sleep facility before trying to adjust your settings. Those were determined by your overnight Titration study to be the settings you needed to most effectively eliminate your apnea's.

If you do decide to try and adjust your pressures, please be careful. Your health is the one thing you don't want to take chances with, obviously.

I was going to highlight the errors in this post, but I would have had to highlight the whole thing.

You're totally CLUELESS! If you have no "good" advice or information.....take your mis-information elsewhere.....or stick around and LEARN some things.....but don't just spew this "garbage".

Den

[ozij]

Using slilcon putty ear plugs to improve FFM seal, by mindy, with a link to photos too.

[Sleeptech010110]

Most masks are built with a leak around 20, to allow CO2 to be blown off. Clinically speaking, leak of 40 is where it's considered to begin to lose effectiveness. Below 40 isn't any big deal.

As explained to me by a representative from Respironics, explaining how the system works and what are and are not acceptable parameters.

Masks are designed to fit comfortably, with a semi-loose fit. Try adjusting the nose bridge around before tightening it, sometimes too tight causes just as much leak as too loose.

Again, as explained by a representation from Respironics. I forgot to mention you shouldn't feel any air leaking, but cranking the mask down extremely tight does make for a very bad leak. Experience confirmed that.

PAP units change pressures almost instantly, so the range from 7-16 would be barely less than half a breath. That is, IF it were a BI/PAP machine.

Again, what the Resp guy said. and from watching the system while Titrating people. It has a real time pressure monitor. It jumps very rapidly.

BI/level pressures are set during testing, the lower number is what you need to exhale with little effort, the higher is what prevents apneas. IF it's a AUTO unit, which is what the therapy mode suggests, then you might have a complex form of apnea, which means it starts at seven and goes up until your apnea is cleared.

As explained to me by my coworker when I started. He was recently fired, so I'm not taking much stock in anything he told me. My apologies for this error.

Either way, your settings are a prescription written by your doctor, please check with your medical supplier or the clinical director of your sleep facility before trying to adjust your settings. Those were determined by your overnight Titration study to be the settings you needed to most effectively eliminate your apnea's.

How is this not true? Your doc writes a prescription for a sleep study, sends it to us. We send the results of the medical test back to him, he sends a prescription to your insurance, who sends it to the medical provider (or some version of that chain of events). And unless you did it yourself, it was determined by an overnight Titration study to be the most effective settings.

If you do decide to try and adjust your pressures, please be careful. Your health is the one thing you don't want to take chances with, obviously.

...Are you saying you do wish to take chances with it?

I was going to highlight the errors in this post, but I would have had to highlight the whole thing.

You're totally CLUELESS! If you have no "good" advice or information.....take your mis-information elsewhere.....or stick around and LEARN some things.....but don't just spew this "garbage".

Den

Obviously a lower leak is better, but as long as it doesn't seem to be affecting the persons sleep, or thier bed partner hasn't noticed any snoring or apneas, that is the guideline we're tought by the company that makes these things to go by when we're trained on them.

Again, I apologize for that one part I was wrong on. Either my coworker mispoke, or was just not too bright. I'm inclined to believe the latter

[TSSleepy]

PAP units change pressures almost instantly, so the range from 7-16 would be barely less than half a breath. That is, IF it were a BI/PAP machine.
BI/level pressures are set during testing, the lower number is what you need to exhale with little effort, the higher is what prevents apneas.
IF it's a AUTO unit, which is what the therapy mode suggests, then you might have a complex form of apnea, which means it starts at seven and goes up until your apnea is cleared.

I am not a sleep tech. I am a complete newbie who has a whopping three nights of CPAP use, so far. I do not own an auto, and have never tried one.

But...I have been reading this site trying to educate myself.

If I understand the concern here, Auto CPAP's gradually increase pressure when they sense an apnea/hypopnea event. If you require 16 to solve an apnea, and it starts at 7 it will bump it a bit (say 7.5?) and then pause to see if it corrected the apnea. Then it will bump it again (say 8.0?) and pause to see if it resolved the apneas.

I have no idea what the actual pressure ramp looks like, but you could be suffering quite a bit while you slowly ratchet from the initial 7 up to the 16 that you need. Thus, the advice to raise the low end some.

[rested gal]

Sleeptech010110, it's cool as far as I'm concerned, that you are hanging in here and continuing to post. It can be a good learning place for anyone willing to sift through it. There will be plenty of misinformation and mistakes, along with nuggets of useful information. We're all human, we can all be right at times and wrong at times.

I think when people use a nickname like Sleeptech, Polysomnoman, ApriaRT -- anything that stands out as being a "sleep professional" -- their posts will be scrutinized more closely for two reasons:

A. people new to "cpap" are glad to see a sleep professional posting, and may be inclined to accept the professional's opinion or statements of fact as correct.

B. cpap users who have been educating themselves about sleep disordered breathing and the machines to treat various kinds of SDB, are also glad to see a sleep professional posting, but will probably be looking at the posts with a more critical eye to see how much the "professional" knows about machines and about treatment after the cpap user leaves the sleep lab or the DME office.

That's good that you re-checked the information you had been given by an erstwhile co-worker who "taught" you about bilevel titration. Good thing you came to this message board, if for that alone.
viewtopic/t38186/viewtopic.php?p=342330#p342330

I don't mean to be dogging you, but here's another little something you might want to check up on. Check with Respironics and ResMed reps about it, 'cause I could sure be wrong:

IF it's a AUTO unit, which is what the therapy mode suggests, then you might have a complex form of apnea, which means it starts at seven and goes up until your apnea is cleared.

If by "complex form of apnea" you're thinking about CSDB (complex sleep disordered breathing, also called CompSAS -- complex sleep apnea syndrome) I don't think an autopap would be prescribed at all if that type of sleep disordered breathing had turned up in a PSG titration. An ASV (adaptive servo ventilator) would be the more likely choice of machine. A ResMed VPAP Adapt SV or a Respironics BiPAP Auto SV.

Also, I don't think "AUTO" (autopap) units are designed to increase pressure until an apnea is cleared. Quite to the contrary as I understand it, when most brands of autopaps are presented with an apnea and are already using a certain amount of pressure (like 10 cm or more with a ResMed machine), they are not going to keep making the pressure go up and up and up "until your apnea is cleared." They'll go up to try to clear flow limitations and snores, yes. But not to try to clear an apnea. A Respironics machine, for example, will try a few incremental pressure nudges, but will back off from that if two or three slight pressure nudges don't improve the airflow.

All that said, you are very welcome here on this message board. I do think you are sincerely trying to help people with your posts. That's what we're all trying to do here, in our own ways. Just be prepared to have your statements scrutinized a little harder than statements from us cpap users, since you present yourself as a professional working in the sleep field.

By the way, I really do like sleep techs. I think you guys and gals are the ones who really "diagnose" the sleep problems and "prescribe" the pressure. Yeah, I know you can't say that -- doctors diagnose and prescribe. But I've got a hunch that quite a few sleep doctors just sign off on whatever the tech reports. I think there are probably a lot of sleep doctors who simply fill-in-the-blanks (probably have a secretary do even that ) with the tech's findings on their final report, and scribble a quick Rx for the pressure the tech found that worked.

Call me cynical, but I'd rather have experienced, knowledgeable sleep techs conducting and scoring my study, than have a great sleep doctor in the background.

[ozij]

When talking to a company rep, always ask to have things backed up in writing. You'll be truly surprised at the time it takes you to get stuff in writing, or at the discerpancies. Never trust anything that is not backed up by official company documentation

The company sites (Resmed and Respironics) have lots of free info about how their machines work - worth studying.

I'm in a rush, so this is very short:
Automatic machines rarely manage to "resolve" a single apnea - especially so if the pressure it soo low. Once an apnea has occured, they will wait for another one within a certain time period, and then raise the pressure. Some wait less, some wait more. For some you can control the response sensitivity. And they all go back down when they think your breathing has settled. They will go back down too low if you let them.
Use the search button to find threads on which alorithm was dicussed by -SWS (the minus is part of his name) and others if you're interested in the algorithms.

RG - that was very very well said.
O.

[Wulfman]

I think when people use a nickname like Sleeptech, Polysomnoman, ApriaRT -- anything that stands out as being a "sleep professional" -- their posts will be scrutinized more closely.....

Sounds logical to me.

Den (still not out to get Sleeptech010110)