Adjustment to new Dreamstation?

[sleepysurgeon]

Hello and thank you for this wonderful board.

I have been using a Resmed Autoset S9 APAP with the Airfit P10 and the Swift FX nasal pillows for the last 5 years.

The results have been a life changer with immense improvement in sleep, total cure of gastric reflux and good improvement in blood pressures.

Since the machine is near the end of its rated life, I pre-emptively bought a new Dreamstation APAP (version 1) last week to use as my primary machine. I planned to keep my S9 as a backup machine.

I set up the Dreamstation with the same settings I used on my S9
I am still using the same pillow masks that I used with the S9

• Start pressure 6 mmH2O, Max pressure 20 mmH2O

• Ramp on, 10 minutes

• AFlex on, Flex 2

• Mask type set to Pillows (Nuance)

My first two nights with the new Dreamstation have been disturbing to say the least:

1. I woke up multiple times in the night
2. The flow seems be much higher and tends to bloat my stomach and produce gas
3. I have an uncomfortable aching sensation in my chest from about the middle of the night
4. I wake up tired and exhausted
5. The max pressures are reaching 17-19 mmH2O compared to around 15 with the S9

• The AHIs have doubled from my usual 3 with the S9 to around 6.5 with the Dreamstation

• Despite the increased flow, there seem to be more vibratory snore events and obstructive events with the Dreamstation. Even a couple of clear airway obstructions.

I switched back to the S9 last night and the improvement was very noticeable, in the quality of sleep, the sleep data and pressures.

What is going on? Help
It is just a case of having to adjust to the new machine?
Do I need to tweak any settings?
CPAP machines are not covered with my insurance so I paid for the new machine.
Should I just cut my losses and buy the Airsense 10 instead since the S9 is no longer manufactured?
I imported the Dreamstation so returning it is not an option.

I have asked a lot of questions, I know but thank you for the patient reading.

[Pugsy]

What is going on?

Different brands...different algorithms for everything including auto adjusting and event flagging criteria.
Exhale relief is different as well....so AFlex at 2 isn't equal to EPR at 2 (if that is what you used on the ResMed).

The higher AHI...doesn't surprise me for a couple of reasons.....you didn't sleep so great for one thing and that in itself can cause a lot of awake/arousal false positive flagging. Plus the auto adjusting algorithm itself is different.

How about comparing the Respironics detailed report to a ResMed detailed report using OSCAR??? Do you use or know about OSCAR?
If not...

OSCAR https://www.sleepfiles.com/OSCAR/
http://www.apneaboard.com/wiki/index.ph ... stallation
http://www.apneaboard.com/wiki/index.ph ... rpretation

Examples of which graphs we need to see can be found here
viewtopic/t158560/How-to-post-images-for-review.html

Should I just cut my losses and buy the Airsense 10 instead since the S9 is no longer manufactured?

I know you wanted to save money but sometimes changing things isn't a good idea.
It is very likely that with some tweaking of the settings you can come up with similar results with the DreamStation as to ResMed results but will take some trial and error.
You could maybe sell the DreamStation and recoup your costs.
So you do have options.

I have experience with both brands. If you are like I was/am...you will likely need more minimum pressure with the DreamStation and maybe some tweaking with the exhale relief to get to where you can comfortably sleep with the DreamStation. Once you don't have the multiple awakenings during the night we can better evaluate the AHI. Right now there's a high probability that the AHI is clouded with false positives. Makes for evaluating pressure needs a bit difficult. None of these machines know if we are asleep or awake. They measure air flow only and awake/arousal air flow can be very irregular when compared to asleep air flow/breathing. They record and respond only to air flow/breathing.
The bloated/aerophagia issues at the higher pressures can also be dealt with once we figure out what pressures are actually needed.
Maybe limit the max a bit if it's algorithm still wants to go high enough to cause belly issues.

[sleepysurgeon]

How about comparing the Respironics detailed report to a ResMed detailed report using OSCAR??? Do you use or know about OSCAR?

Thanks so much for taking the time to help out!
I have attached three screenshots:

1. The typical daily report I used to get on the S9

1. RESMED INITIAL.png (106.15 KiB) Viewed 684 times

2. Last night's report from the Dreamstation

2. Dreamstation.png (131.62 KiB) Viewed 684 times

3. A quick report from when I switched back to the S9

3. BackToS9.png (113.66 KiB) Viewed 684 times

I know you wanted to save money but sometimes changing things isn't a good idea.

I completely agree with you.
I just got tempted because the supplier quoted $389 for the Dreamstation vs $569 for the AS10
Money is tight with the pandemic in full swing!
I was prepared for some minor disturbances but not such a rude culture shock on using the Philips machine.
Costly lessons to learn!!

[Pugsy]

The Respironics report just screams poor sleep and probably lots of false positives.
You can do some crash course learning about false positives here. Bear in mind it is talking mainly about centrals/CAs but we can have false positives in any event category.
http://freecpapadvice.com/sleepyhead-free-software

It's nearly impossible to figure out what pressure settings you might need with the DreamStation when having so much probable arousal false positives. Unfortunately it's hard to get good sleep when things are new and difficult to adjust to. Damned if you do and damned if you don't.

If you want to try....and since you seem to be having belly discomfort issues as well.
Your ResMed minimum is 6 with EPR set to 1 and the DreamStation is 8 with AFlex set to what appears to be 2.

Flex has more to do with timing of the change from inhale to exhale than it has to do with the actual drop during exhale. What I normally tell people when trying Flex is to simply experiment with all the setting for AFlex (including off) and choose the one that simply feels more natural to them no matter what the setting. I have always believed that we need to be comfortable to be expected to sleep decently. So I suggest doing whatever it takes to be comfortable.

The fact that you chose 2 different minimums might have contributed to the aerophagia/bloat issues. You used a higher minimum all night which might have contributed to the bloat discomfort and thus the sleep quality as well.
It's always hard to know if it is the minimum or the maximum that causes the belly issues. Since you had times on the ResMed where the machine went higher for some of the time and you didn't have belly issues...makes me wonder if your minimum is your undoing.

Unfortunately sometimes we have to make some educated guesses here but hurts nothing to at least try.

If I were in your shoes I would reduce the minimum back to 6...and yes I know that Respironics machines historically are slower to respond but in this situation what I want is a good chunk of solid sleep first so we can best evaluate pressure needs.
Plus we have to try to remove the belly issues because people don't sleep so great when their belly's hurt.

We have to get the solid sleep first...

I would play with AFlex settings...all of them and simply choose whatever feels more natural to you.

I would limit the max (for now only) to 15 just to reduce the chance of the max being a factor in the belly issues. I know the machine will likely hit the max and that's okay for now.
The goal right now is better sleep so that we can better evaluate the pressure setting needs.

Your choice...I know the price is/was attractive and you may or may not be able to duplicate the results with this new machine but it might be worth at least trying.

[JXG]

I don't think there is a "Pillows" mask type setting on the Dreamstation, so maybe take another look at that setting and make sure you have it right? It should be something like "X1" (the number depends on the size of your Nuance mask, so you'll need to look that up). If you set the Dreamstation Mask Type setting too high then it could boost the pressure and result in the uncomfortable feeling you described because it is designed to compensate for the air restriction in the mask (this is different than Resmed mask type setting).

[sleepysurgeon]

I don't think there is a "Pillows" mask type setting on the Dreamstation, so maybe take another look at that setting and make sure you have it right?

Thank you! I looked it up now and my Airfit P10 would correspond to X2 (for the medium pillow). X1 would be for the large pillows (for anyone out there who is looking).

[sleepysurgeon]

The Respironics report just screams poor sleep and probably lots of false positives.

Thank you! I educated myself a bit on detecting false positives from the videos you recommended.
My data seems to suggest that these are NOT false positives for the most part.
A lot of it may be positional due to chin drop.
Funny though, that this was not a major issue with the S9!

So I suggest doing whatever it takes to be comfortable.
Since you had times on the ResMed where the machine went higher for some of the time and you didn't have belly issues...makes me wonder if your minimum is your undoing.
If I were in your shoes I would reduce the minimum back to 6...
I would play with AFlex settings...
I would limit the max (for now only) to 15 just to reduce the chance of the max being a factor in the belly issues.

Some really useful suggestions!
I did almost exactly what you suggested:

• Changed AFlex to 1

• Turned Ramp off

• Reduced minimum to 6 and max to 16

I did sleep much better.
No bloating at all today.

Just few things I am concerned about:

• The 95% was at the max 16
  • AHI went up further to 7.1 (very few false positives)
  • The machine did not record the flow rate for the first part of the night.
  • Woke me up with a series of alarms and an error code on the screen. I reset the machine by powering on and off, thereafter it behaved as it should.

  

  Dreamstation-Modified settings-1.png (130.6 KiB) Viewed 632 times

[Pugsy]

Was the SD card in your DreamStation at the first part of the night when there is no flow rate graph?
That would explain the no flow rate. The SD card MUST be in the cpap machine correctly if we get flow rate data because those files are written directly to the SD card.

You need to understand what 90/95% numbers mean...it just means you were AT OR BELOW that number for 90/95 % of the night.
It is NOT where you were at for 95% of the night.

The goal last night was to at least get you to sleep with the machine. I knew you would hit the max and I expected the AHI to go up a bit.

I have no idea why it decided to go weird on your with alarms and all that. I know of no reason for the DreamStation to be sounding alarms. I didn't even know it had alarms. Do you remember the error message you saw on the screen?
BUT...that would be a legitimate warranty issues to justify returning the machine....just saying...if it should make a habit of it.
The only alarm I know of with these regular cpap machines is a large leak alarm and you never hit large leak.

Do you spend much time on your back?

[sleepysurgeon]

Was the SD card in your DreamStation at the first part of the night when there is no flow rate graph?

Thank you again for taking the time and effort to respond!
Yes. The card had been in the machine from the start! No idea why it was not recording for the first part of the night till the alarm!

I know of no reason for the DreamStation to be sounding alarms. I didn't even know it had alarms. Do you remember the error message you saw on the screen?

The Dreamstation does have alarms. I just downloaded a (2018) manual and it has this listed.

Alert.jpg (42.31 KiB) Viewed 611 times

I should have recorded the error code but was too sleepy and disoriented in the middle of the night!
I seem to have serendipitously done the right procedure to deal with the error as per the manual. Power off and back on again!

Do you spend much time on your back?

I am predominantly a side sleeper (right lateral position to be precise)
Less than 30 minutes of the night would be on the left lateral and maybe 10 minutes or so in the supine.
I do use TWO pillows due to a hereditary cervical spine issue which may contribute to the chin drop.

[Pugsy]

The missing flow rate data files likely is related to whatever caused the alarm. I have no idea what that might be.
There are error codes written somewhere in the machine memory where people who work on these machines can service them but I don't know of any way for us to figure it out.

If this continues to happen....definitely grounds for machine warranty return.

Next experiment...when you are ready and think you can sleep....start increasing the minimum pressure and lets see if more minimum causes the belly issues or not. I suggest small increases but it's up to you how gutsy you want to get.

The goal is to find pressures that deal with the OAs/hyponeas and don't cause belly issues.

Don't worry about hitting the max at this time. With a more optimal minimum we might find that there is less time at the max.

Remember...if you aren't asleep then we really can't evaluate the data well at all. So sleep is critical.