breathing and sleeping problems with S9 Autoset

Greetings!

I've been reading this forum as a guest while I was waiting to have a sleep study, but now that I've received an S9 Autoset I wanted to introduce myself. I've read very useful posts on this site about people getting started. However, naively, I did not realize at the time I purchased the machine that it did not actually come with a CD of the Resscan 3.12 software - I just assumed that the software was included! The CPAP suppliers seem to be discouraged from providing this software to customers. You are supposed to keep going back to a sleep specialist for even very minor adjustments. The time, distance and money involved (I have no insurance) means that it is out of the question to keep seeking out an expensive specialist for each minor change.

The doctor at the sleep clinic I visited recommended trying out titration in the range of 8-12cm to see how much I am able to tolerate, while also varying the position I sleep in to try to lessen the most severe apneas (I normally sleep on my back). However, now the S9 Autoset machine has already been set in regular CPAP mode at the higher end of that range (without the autoset or EPR). I was told I could make changes in the machine settings at any time, but the clinician's manual I found posted implies that this can only be done using Rescan 3.12 software, which I don't know how to obtain.

In spite of having good sleep during the sleep study, since getting the S9 at home I have been unable to fall asleep without taking it off. The maximum ramp time is 45 minutes, which is not enough time for me to get accustomed to the pressure and fall asleep. It requires more effort to breathe out which is too distracting. The air coming out of the front of the mask is not too distracting when I lie facing up, but if I sleep on my side as the doctor recommended, the air hisses and blows back at me from the pillow.

What is the best way to obtain the software and adjust the S9's settings? Should I begin with the Autoset function, or first try a fixed titration at the lower end of the range the doctor stated? Is lying on your side very important, and if so how to minimize the air hissing and blowing? Is there a particular kind of pillow that is best for this?

I am using the nasal pillows, and wonder if one of the other types of masks might be less distracting and irritating when I'm trying to fall asleep?

Also, is it true that there is a new S9 bi-level machine coming out soon? Is it likely to be priced far above the S9 Autoset and would it be a worthwhile investment as a last resort if all else fails?

I'm grateful for any advice as I'm getting started and I'll try to post updates as I overcome (hopefully) all these obstacles.

johnsx1 wrote:Greetings!

I've been reading this forum as a guest while I was waiting to have a sleep study, but now that I've received an S9 Autoset I wanted to introduce myself. I've read very useful posts on this site about people getting started. However, naively, I did not realize at the time I purchased the machine that it did not actually come with a CD of the Resscan 3.12 software - I just assumed that the software was included! The CPAP suppliers seem to be discouraged from providing this software to customers. You are supposed to keep going back to a sleep specialist for even very minor adjustments. The time, distance and money involved (I have no insurance) means that it is out of the question to keep seeking out an expensive specialist for each minor change.

The software is technically not for sale to patients in the US for reasons that apparently have to do with worries on insurance companies/dmes/resmed's part that I don't really understand. Others might shed more light as to why the software is not for sale to US patients.

However, if you PM a user named Uncle_Bob, he will provide you with links for both the ResScan software and the clinical manual for the S9.

The doctor at the sleep clinic I visited recommended trying out titration in the range of 8-12cm to see how much I am able to tolerate, while also varying the position I sleep in to try to lessen the most severe apneas (I normally sleep on my back). However, now the S9 Autoset machine has already been set in regular CPAP mode at the higher end of that range (without the autoset or EPR). I was told I could make changes in the machine settings at any time, but the clinician's manual I found posted implies that this can only be done using Rescan 3.12 software, which I don't know how to obtain.

You don't need the software to change the settings on the S9. You do need to get into the clinical menu, however. You can do that by pressing the big round knob and the double check mark button together for about 3 seconds. The clinical menu should show up on the LCD. But get and read the clincial manual before you try fiddling around with any of the settings in the clinical menu.

In spite of having good sleep during the sleep study, since getting the S9 at home I have been unable to fall asleep without taking it off. The maximum ramp time is 45 minutes, which is not enough time for me to get accustomed to the pressure and fall asleep. It requires more effort to breathe out which is too distracting. The air coming out of the front of the mask is not too distracting when I lie facing up, but if I sleep on my side as the doctor recommended, the air hisses and blows back at me from the pillow.

Several comments about this:

1) Later on you say you're using a nasal pillows mask. Is it the Swift FX? If so, lots of folks have had problems with the exhale port air bouncing off the bed pillows and blankets and being bothersome. I have found this the single most irritating thing about that mask. I have found that if I make sure there is a small pillow/blanket free area for the exhale air to go into, that it's much better. I"ve also found that I can use one hand to shield my eyes from the reflected air by keeping my hand close enough (but NOT ON) the exhale vent to reflect the flow off my hand and away from my face.

2) Lots of folks have trouble learning how to fall asleep (and stay asleep) with the mask on. You can search the forum for other posts by users with this problem. Once common suggestion is in the early going, take some time to desensitize yourself to the mask and air blowing in your nose by taking the CPAP machine into a different room and using it when you're awake and sitting comfortably in a nice soft chair/recliner while you watch TV or read for a couple of hours at a time. I'd add to this advice---DO THIS FAR AWAY FROM BEDTIME.

3) If EPR is not turned on, you should turn it on. It may make it easier to breathe out against the air for you. If the problem of it being too difficult/hard/distracting to exhale persists and continues to prevent you from getting a good night's sleep after a month or two of use, make sure you report this to your sleep doctor's office. There are things they might be able to suggest you try.

4) DO NOT LIE IN BED (with the mask on) FOR OVER AN HOUR OR MORE IF YOU CAN'T GET TO SLEEP! As counter-intuitive as it sounds, lying in bed fighting to go to sleep when you can't seem to get to sleep just aggravates your bedtime-insomnia. I'd suggest the following tips for dealing with bedtime insomnia:

• A) Wait to go to bed until you are feeling so sleepy that you can't keep your eyes open. And note that feeling sleepy is NOT the same as feeling tired or exhausted. Try to make sure that you've got everything CPAP-related ready well before bedtime. That might even include washing your face and brushing your teeth well before you plan on going to bed.
  
  B) If you can't get to sleep by the time the ramp time is done (45 minutes), then get up out of bed and go into a different room. If you haven't fallen asleep in 45 minutes, you're fighting to hard for sleep. It's better to get up, go into a different room and do something very quiet and soothing until you start to feel sleepy again. Do NOT watch TV or read or web browse since those activities are more likely to WAKE you up instead of helping you get SLEEPY. For me, I find sitting in a darkened room and listening to very quiet music helps me relax and get sleepy when I can't get to sleep.
  
  C) Pay more attention to your sleep hygiene. In particular, try to cut way back on both caffeine and alcohol anywhere close to bedtime. Increasing exercise can help---but try to get the intense exercise done well before bedtime. Conscious relaxation techniques such as meditation or deep breathing or yoga near bedtime can also help you get sleepy enough to fall asleep once you're in bed.
  
  D) If the bedtime insomnia gets worse or starts to interfere with your daytime functioning, then let your sleep doctor's office know about it. They may or may not be able to give you any useful tips on dealing with it. They may or may not be willing to prescribe a sleep aid. But if the insomnia is bad enough that it's creating as many day time problems as the apnea was, they need to know about it.

Also, is it true that there is a new S9 bi-level machine coming out soon? Is it likely to be priced far above the S9 Autoset and would it be a worthwhile investment as a last resort if all else fails?

Boy do I wish I knew the answer to this question since my sleep doctor has ordered a bi-level titration for me on Tuesday with a follow-up on Nov. 30 because of all the issues I've had trying to adjust to my S9. After 8 weeks of 100% compliance, I am still feeling worse or (on better days) no better than I was pre-CPAP and I'm still yawning during the day most days and fighting bedtime insomnia on many nights.

John, You have got the best unit currently available, IMO. Get the free software from Uncle Bob's posts, there is a link to the free download site. You can also download the clinicians manual there too! He's great help here. I agree with Robysue's post, she has learned several pointers while trying to adjust to her therapy. I would run it in auto at 6/12 for one week and see what is happening. You will want EPR turned on for your comfort. I would add that if you are sinking into your pillow enough to have exhaust blowing into it, fold it in half and place your face near the edge, or replace it with a firmer one. You can also place two soft pillows in one pillow case to firm it up. Good luck! john

you do not need the software to change the settings. Just push setup button and the round button at the same time for 3 seconds...

Thanks to all who responded so quickly and with specific advice. I guess this is old news to all of you but I simply find it amazing that the actual Resmed operational manual is kept secret from users. "Only settings relevant to the patient are displayed in the Patient Setup menu." Unbelievable.

I've been able to record 2 nights sleep, and have just figured out how to view it in the software. Before recording, I set the clock incorrectly and later got an error when I tried to reset it to the correct time. I was forced to delete all the stored data before the machine would let me reset the clock, so before doing that I generated 2 reports. The second night is broken up between two reports due to the wrong clock time. I am sorry to post such simple questions when there are so many advanced topics on this forum, but I would appreciate it if anyone could have a look at the charts below and give me some thoughts on my mixed results.

In general, I did not have so much trouble getting to sleep as my earlier attempts, and was less bothered by air hissing (I changed pillows - thanks for the advice on that), though it was still a major annoyance when on my side. I used the 45 minute ramp time again, and I set the auto range to 6-12 (my doctor suggested I try fixed CPAP starting at 8cm and going up several cm later if that wasn't sufficient). I turned on EPR. I took the mask off or partly off in frustration a few times during the night but put it back on quickly each time, and obviously the machine doesn't know how to interpret this. I also consciously stopped breathing for a moment or had very irregular breathing a number of times while awake when I found the pressure felt too annoying to breathe naturally - I assume that didn't happen while asleep, but the machine obviously doesn't know when I'm sleeping and when I'm awake.

On the first night, I slept longer than normal. I felt more refreshed than usual on waking up.










The second night was much worse than the first. I woke up several times during the night, and did not feel refreshed at all in the morning. I don't know what the problem was to make the second night so much different than the first - I changed no settings. These charts cover the second part of the second night due to the clock error.










I don't know quite how to interpret this but I guess that I should raise both upper and lower values gradually to see if my sleep becomes better and more consistent as a result. Thanks for reading.

Hello John,
We seem to be at the same stage in home CPAP equipment and accumulated results. But you've said nothing about your lab sleep study dx and home PAP objectives.
After a quick look at your screen dumps from ResScan:
- I note a correlation between flow Pressure increases and Leakage
- you have one stage when you piled up a whole bunch of Black events. I won't call them any particular type of apnea, rather zoom in on the time curves to possibly see what is happening; in my case I was accumulating nasal congestion, which resulted in waking up.
- would be interesting to find out from the flow curves whether one has changed body position between supine and side

John,

All those black flags are apneas that the ResMed S9's software believes are central apneas---in other words, apneas caused by your body "forgetting to breathe" rather than obstructive apneas, which occur when your airway collapses and you can't breathe even though your body is trying to breathe.

The apneas the S9 thinks are centrals are also why the pressure was not increased during those clusters of events: More pressure sometimes causes additional central apneas to occur and so the S9 is programed to NOT increase pressure when it thinks the apnea is a central one.

I personally would not be increasing either the min or max pressure settings at this point if I were you: There's no solid evidence from these nights that the S9 thinks you need more pressure and the number of red flags (obstructive apneas) is nice and low. So these pressures are adequate to keep your airway from collapsing. And higher pressures can trigger additional central apneas in some people.

So the real question that needs to be investigated is the large number of central apneas. Did your initial sleep study show any centrals? Did you have a titration study at all? Or is the doctor basically asking you to do an auto-tritration at home with the starting range of 8--12cm? I'd suggest phoning the doctor, telling him that you're worried about the large number of central apneas, and maybe faxing him the ResScan reports including the detailed graphs showing the number and type of events and see what his professional advice is. He might very well actually suggest that you lower than upper pressure limit to 10cm. He might also tell you to watch the centrals and see if they start to decrease on their own in a week or so---some people do temporarily have some centrals when they first start CPAP, but as their body gets used to breathing with the machine, the number and severity of the centrals starts to decrease on its own.

Now the leak data seems to indicate that you've got enough leaks that it's probably bothering you (a lot?) at night. So working on the leaks will increase your comfort (and hence your ability to sleep all night) as well as increase the effectiveness of the therapy. However, as bad as your leaks are in these graphs, it also looks to me like they are not bad enough for the Green Smiley to a Red Frowny in the short Sleep Quality menu on the S9's LCD. And that indicates that your leaks are not yet severe enough for the S9 to flag them as definitely compromising the data and the therapy.