Same settings on diff. paps - different outcome - any ideas?

[Andréa]

Hi!

Me again, still struggling to optimize treatment Will continue this until I'm 6 ft. under... as I feel that my sleep quality is what rules my energy during the day. Shitty sleep and I'm a brainfogged dizzy zombie unable to get out of bed, ok sleep and I manage to have conversations, write this and do som actual thinking - it's a word of difference. I have, as said before, underlying chronic illnesses: ME/Cfs, hEDS and probably some autoimmune shit that hasn't yet been evaluated and dx.

As I haven't done a PSG, due to lack of staff att the hospital (the health care system in Sweden is in full blown crises) so I don't know how my base line sleep quality is - other than absolutely not ok. Slept like a log until I became a mother, 10 yrs ago, and my baby didn't sleep, seemingly at all, for the first six years. Needless to say that me and my husband both aged like 40 years in these first parenting years. Somewhere in that tornado my body shut down, my sleep got totally FU and I finally got dx with severe SA. Had been asking dr. for years, due to me being a super snorer, having constant palpitations, blood sugar issues, fatigue etc. and that my husband heard me stop breathing through out the night, but being a slim woman with no high BP - I couldn't possibly have SA, it had to be anxiety Needless to say, therapy didn't sort out my SA. My god, there are so many nonchalant and not well educated MD:s... Think I've met them all

Anyhow.

I have to machines - one Resmed 10 auto and one Resmed Lumis 100 ST. I almost always use the former as I haven't, according to my pap-nurse (that only check my basic stats. like overall AHI and such - he doesn't go in and analyze FL, FR etc., the Oscar-data), any issues that seem to require a more advanced machine. He's probably right but I can't stop digging in Oscsar and trying out diff. settings in hope to find where my body gets the best sleep and breathing patterns.

I tried both my machines at the same settings Auto 5.6/7 no EPR and Lumis ipap 7 epap 5.6 - and the outcome is quite different, which interests me. Also I feel better when my numbers are shittier (Lumis) and the flow rate curve, RR look worse. I use a Wellue ring to track oxygen and pulse - these nr looks quite the same, and seemingly alright, regardless machine (and settings).
- Any hypothesis regarding this, the different outcomes? (BTW - why doesn't Lumis show FL?)
- Why do I feel better when numbers and curves look worse? Is it because I sleep so poorly that adrenaline kicks in and give me "false" energy from the body being in more stress? I have the setting S which is regular bi-level as far as I can tell.
- Is it possible to also have UARS that fragments my sleep, but doesn't show up bc i wake before any FL och desats happen? Don't know what to do about that anyway as the treatment is pap... Wish I could be sedated every night . I have to prompt for a PSG somehow.

(This autumn I've tried for months to upper my settings, using my Autoset, with a pressure of 9-12 (titrated from minp 6 to 9), and I got so sick. After diving in to research I'm convinced that I had symtoms of high intercranial pressure; pressure headache, eyes about to be pushed out of their sockets, cognitive impact and, extreme exhaustion, feeling of being oxygen deprived - felt I was about to die. So - a min.pressure above 7 is out of the question for me - that's where my cut of is. And max.pressures above 10 isn't an option either as I get too sick. And, my numbers aren't any better on higher settings.)

Due to my sleep being so bad I often fall asleep closer to the early morning hours. Just fyi.

Btw - I wrote to Riccardo Stoohs regarding his latest research Association with the apnea-hypopnea index and somatic arousal https://www.sciencedirect.com/science/a ... via%3Dihub - anyone read? It's very interesting and highlights that AHI isn't the best way to determine the severity of SA, that AHI lower than 50 doesn't actually correlate with the burden of symptoms that patients have. I feel this to fall well into what one sees in SA-forums, that people with according to AHI - has mild SA can be very ill, and others with an AHI of 40 can be quite symptom free. In general I feel that this SBD world has a really long way to go yet, to entangle and find solutions for best dx and treatments.

Have a nice day, or good night - depending on what time zone you're in. <3


https://imgur.com/a/njj5iS3

[ozij]

I tried both my machines at the same settings Auto 5.6/7 no EPR and Lumis ipap 7 epap 5.6 - and the outcome is quite different,

Those are not even faintly the same settings.

You set up the Auto to vary the pressure it supplies between a minimum of 5.6 and maximum of 7. In addition, you set it up to supply the same pressure regardless of to whether you're inhaling or exhaling: no Exhale Pressure Relief.
You set up the bi-level machine to supply a constant Inhale Positive Air Pressure of 7, and a constant Exhale Positive Air Pressure of 5.6. It is to be expected the results will be different.

The chart you posted indicates your pressure is too low and your breathing disturbances are undertreated. The Hypopneas seem to pop up in batches about ever 90 minutes - which makes me think you're breathing is much worse when you slip into REM sleep. That means you may benefit from a setting that raises your pressure when your breathing starts obstructing, and drops it when that's not necessary: i.e. some kind of automatic pressure adjustment.


If you want to understand the differences in results, please post some nights on the APAP - both at the lower pressures, and the higher ones.
And, if you logged the info, tell us how you felt after that specific night.

[palerider]

I have to machines - one Resmed 10 auto

"resmed 10 auto" WHAT? We can *GUESS* (And I think that ozij probably has guessed right, but we can't be sure.

and one Resmed Lumis 100 ST.

The Lumis 100 ST is a *VENTILATOR*, nowhere even remotely close to the same sort of machine.

- Any hypothesis regarding this, the different outcomes? (BTW - why doesn't Lumis show FL?)

see above, you're trying to compare apples and bulldozers.

[ozij]

From a recent post by rubicon:

BTW I don't believe an S/T machine is going to report F/Ls because the breaths are "tailored" by the machine. The flow waveform you see is manufactured by the machine, not the patient (IOWs, it's hard to claim Inspiratory Flow Limitation if the machine is shoving the breath in).

I'm looking at an S9 Lumis 150 and FL isn't there. IDK if that's true of all S/T machines, but regardless, now you have to really think about the waveforms (is it a T or an S?) instead of relying on the machine interpretation.

[robysue1]

I have to machines - one Resmed 10 auto

"resmed 10 auto" WHAT? We can *GUESS* (And I think that ozij probably has guessed right, but we can't be sure.

The data that Andréa posted back in viewtopic.php?f=1&t=186111&p=1433982#p1433982 clearly comes from a Resmed AirSense 10 AutoSet. This is one time when I think keeping to the same thread, or at least referencing the original thread, would have been useful.

[ozij]

This is one time when I think keeping to the same thread, or at least referencing the original thread, would have been useful.

Agreed. But I suggest we stick to the present thread, because the data from the use of a ventilator is here (above), the results look awful to my eye.
And here's the Resmed Air Sense Auto data from February:

[robysue1]

I have to machines - one Resmed 10 auto and one Resmed Lumis 100 ST.

As ozij (and palerider) have pointed out, the Resmed AirSense 10 AutoSet and the Resmed Lumis 100 ST are vastly different machines in terms of their algorithms and in terms of what they are designed to do.

To add to what they've said:

The Resmed AirSense 10 AutoSet is an auto adjusting CPAP designed to treat ordinary OSA---i.e. obstructive sleep apnea. The data you posted in your other thread indicates you were (are?) using the AutoSet in Auto mode. In Auto mode, the machine increases the pressure in response to specific things going on in your breathing.

The Resmed S0 Lumis VPAP 100 ST is a bilevel PAP ventilator that can be set in many different modes. The mode you are using in the data you posted is BiPAP - S (according to Oscar), and is most likely referred to as "S" mode on your machine and in its clinical manual. "S" mode is a fixed pressure bi-level mode with one fixed pressure (EPAP) for exhalation and another fixed pressure (IPAP) for inhalation. The Lumis 100 ST does not adjust the pressure in response to what is happening in your breathing when you use "S" mode.

I tried both my machines at the same settings Auto 5.6/7 no EPR and Lumis ipap 7 epap 5.6 - and the outcome is quite different, which interests me.

As others have pointed out, Auto 5.6-7 is not at all the same as Lumis IPAP = 7, EPAP = 5.6. When you use the Auto machine, the pressure is increased when you start having events. When you use the Lumis, the pressures are fixed, all night long. You start having events, and the machine does not increase the pressure because it cannot increase the pressure. More on this in a bit.

Also, the data that you posted earlier (in this thread) showed your AutoSet's settings as 6-11cm with EPR = 2. When did you change the settings on the AutoSet to 5.6-7 with EPR = Off? And why did you change the settings?

I almost always use the former as I haven't, according to my pap-nurse (that only check my basic stats. like overall AHI and such - he doesn't go in and analyze FL, FR etc., the Oscar-data), any issues that seem to require a more advanced machine. He's probably right but I can't stop digging in Oscsar and trying out diff. settings in hope to find where my body gets the best sleep and breathing patterns.

What issues are you worried about that you believe require the more advanced machine??

In other words, are you digging through your Oscar data in hopes to find a magic bullet item---something that screams, "FIX THIS" and then all your sleep problems will be addressed?

I ask because that's not likely to happen. The AutoSet data you posted your other thread doesn't actually look that bad:


Yes, the AHI = 3.08, and a bunch of people here will tell you its still too high. But those two clusters of CAs (which drive the whole AHI up) are both most likely sleep-wake-junk. They occurred when you were not really sound asleep. They probably represent normal pauses in breathing as the body tries to transition from wake to sleep. And the problem is not the CAs: Rather the problem is that it took you a while to get back to nice, sound sleep.

Likewise, the flow limitations at the beginning of the night? Again, it looks to me like you were struggling to get to sleep. And the problem is not so much the flow limitations (which are likely not real because they're occurring when you are awake), but rather the very fact that it took you an hour before genuinely sound sleep was established.

Now, let's contrast that data from the AutoSet with the data you posted today:

Clearly an EPAP = 5.6cm is not enough to prevent your apnea. As ozij mentions, all those clusters of Hs seem to occur in clusters that are about 90 minutes apart, which indicates that your OSA may be worse (potentially much worse) in REM than in non-REM sleep.

And because you were using the Lumis 100 in "S" mode, the machine could do nothing in response to all those Hs. Indeed, because the Lumis has a fixed EPAP in all its modes (if I recall correctly), there's not much this machine could have done to address the problem regardless of what mode you were in.

If you want to keep using the Lumis, you're going to need to increase the EPAP pressure. How high? I'd use the fact that when you were using the AutoSet with a pressure range of 6-11cm and EPR = 2, your effective 95% EPAP was about 7.18 cm. So that means that you most likely need to set the EPAP on the Lumis around 7cm in order to prevent those clusters of Hs from occurring.

[robysue1]

Now lets look at the rest of what you've written today:

Me again, still struggling to optimize treatment Will continue this until I'm 6 ft. under... as I feel that my sleep quality is what rules my energy during the day. Shitty sleep and I'm a brainfogged dizzy zombie unable to get out of bed, ok sleep and I manage to have conversations, write this and do som actual thinking - it's a word of difference. I have, as said before, underlying chronic illnesses: ME/Cfs, hEDS and probably some autoimmune shit that hasn't yet been evaluated and dx.

ALL those other chronic illnesses have to be addressed and properly managed before your sleep is going to improve. PAP fixes sleep disordered breathing and not anything else. If other conditions in addition to the OSA are making your sleep quality shit, you have to fix those other conditions as well as the OSA in order to improve the quality of your sleep. Please read what I wrote on your other thread about the ME/Cfs and hEDS.

As I haven't done a PSG, due to lack of staff att the hospital (the health care system in Sweden is in full blown crises) so I don't know how my base line sleep quality is - other than absolutely not ok. Slept like a log until I became a mother, 10 yrs ago, and my baby didn't sleep, seemingly at all, for the first six years. Needless to say that me and my husband both aged like 40 years in these first parenting years. Somewhere in that tornado my body shut down, my sleep got totally FU and I finally got dx with severe SA.

If you haven't had a sleep study, how was the diagnosis of severe sleep apnea made?

And how severe is the untreated sleep apnea? Here in the US, "Severe Sleep Apnea" usually refers to a diagnostic AHI of at least 30 on some kind of a formal sleep test, although increasingly the diagnostic sleep tests are done at home rather than in a hospital/sleep clinic lab.

Also I feel better when my numbers are shittier (Lumis) and the flow rate curve, RR look worse. I use a Wellue ring to track oxygen and pulse - these nr looks quite the same, and seemingly alright, regardless machine (and settings).
- Any hypothesis regarding this, the different outcomes? (BTW - why doesn't Lumis show FL?)

There's more to how we feel than the AHI and even the flow rate curve.

One possible hypothesis for why you might feel better on the Lumis: Your body is so sensitive to the changing pressures on the AutoSet that your sleep is just simply more fragmented with spontaneous arousals when you use that machine. In that case, you might do much better using the Lumis in S mode with EPAP = 7cm and IPAP = 9cm.

And the Lumis doesn't show a FL curve specifically because it is programmed not to record that data: Since "S" mode does not increase pressure, the programmers decided that the flow limitation data---which is primarily useful for explaining why an auto adjusting machine increases pressure---is just. not needed.

- Why do I feel better when numbers and curves look worse? Is it because I sleep so poorly that adrenaline kicks in and give me "false" energy from the body being in more stress? I have the setting S which is regular bi-level as far as I can tell.

No, the adrenaline kicks (which I used to have with my untreated OSA are more likely to cause arousals and trigger things like sleeping with your hands and feet in "fists". At least that's what used to happen to me: I'd wake up with my hands in genuine fists and my feet would be curled into what my husband and I called "feet fists". I'd also wake up feeling like I'd been fighting all night long. Not restful at all.

My best guess is that you feel better when the numbers look worse because other than the under-treated OSA, your overall sleep quality is somehow better. My hypothesis would be you are among the group of PAPers who do better on fixed pressure simply because the auto adjusting pressure algorithm itself triggers some spontaneous arousals.

Try bumping up the EPAP to 7cm (which is where you other data indicates it needs to be) and your IPAP = 9cm on the Lumis while running in S mode. That might give you better AHI numbers, a smoother flow rate curve (i.e. less flow limitation) and still give you better sleep than you were getting on the AutoSet.

- Is it possible to also have UARS that fragments my sleep, but doesn't show up bc i wake before any FL och desats happen? Don't know what to do about that anyway as the treatment is pap...

On my diagnostic test, the vast majority of my events were scored as something called "Hypopneas with arousal", which basically meant that, yes, I was arousing before the O2 desats happened. And yes, the treatment is still PAP.

So the question comes back to learning how to sleep well with the PAP machine. And for some folks, that's a steeper hill than it is for others.

Wish I could be sedated every night .

In all seriousness, it might be a decent idea to try something like Ambien or Belsomra or some other prescription sleep aid for a while. In my case, my sleep quality with PAP started to improve after I did some pretty hard CBT-I to work on "consolidating" my sleep cycles. But further improvement was only achieved after using Belsomra for about a year or two pre-pandemic.

[palerider]

I have to machines - one Resmed 10 auto

"resmed 10 auto" WHAT? We can *GUESS* (And I think that ozij probably has guessed right, but we can't be sure.

The data that Andréa posted back in viewtopic.php?f=1&t=186111&p=1433982#p1433982 clearly comes from a Resmed AirSense 10 AutoSet. This is one time when I think keeping to the same thread, or at least referencing the original thread, would have been useful.

Indeed, thank you.

[palerider]

From a recent post by rubicon:

BTW I don't believe an S/T machine is going to report F/Ls because the breaths are "tailored" by the machine. The flow waveform you see is manufactured by the machine, not the patient (IOWs, it's hard to claim Inspiratory Flow Limitation if the machine is shoving the breath in).

I'm looking at an S9 Lumis 150 and FL isn't there. IDK if that's true of all S/T machines, but regardless, now you have to really think about the waveforms (is it a T or an S?) instead of relying on the machine interpretation.

I'm not 100% sure, but I don't believe the Lumis 100 ST is a "S/T" machine, I believe it's what is called the "ST-A" here, which means it's Resmed's iVAPS non-invasive ventilator.

it does have a S mode (being used, T, ST, PAC and iVAPS modes.

[robysue1]

I'm not 100% sure, but I don't believe the Lumis 100 ST is a "S/T" machine, I believe it's what is called the "ST-A" here, which means it's Resmed's iVAPS non-invasive ventilator.

it does have a S mode (being used, T, ST, PAC and iVAPS modes.

The OP's Oscar data describes the machine as a Resmed S9 Lumis VPAP 100 ST. When I google that, the only links that come up are to the current AirCurve 10 VPAP ST machines.

Was there a VPAP in the S9 line?

For what it's worth, both a Lumis VPAP 100 ST and a Lumis VPAP 100 ST-A are listed on the Product Support Page on the Resmed web pages.

[zonker]

I'm not 100% sure, but I don't believe the Lumis 100 ST is a "S/T" machine, I believe it's what is called the "ST-A" here, which means it's Resmed's iVAPS non-invasive ventilator.

it does have a S mode (being used, T, ST, PAC and iVAPS modes.

oh, dear!

you just made my head spin!

[ozij]

One possible hypothesis for why you might feel better on the Lumis: Your body is so sensitive to the changing pressures on the AutoSet that your sleep is just simply more fragmented with spontaneous arousals when you use that machine. In that case, you might do much better using the Lumis in S mode with EPAP = 7cm and IPAP = 9cm.

My best guess is that you feel better when the numbers look worse because other than the under-treated OSA, your overall sleep quality is somehow better. My hypothesis would be you are among the group of PAPers who do better on fixed pressure simply because the auto adjusting pressure algorithm itself triggers some spontaneous arousals.

Try bumping up the EPAP to 7cm (which is where you other data indicates it needs to be) and your IPAP = 9cm on the Lumis while running in S mode. That might give you better AHI numbers, a smoother flow rate curve (i.e. less flow limitation) and still give you better sleep than you were getting on the AutoSet.

- Is it possible to also have UARS that fragments my sleep, but doesn't show up bc i wake before any FL och desats happen? Don't know what to do about that anyway as the treatment is pap...

[On my diagnostic test, the vast majority of my events were scored as something called "Hypopneas with arousal", which basically meant that, yes, I was arousing before the O2 desats happened. And yes, the treatment is still PAP.

So the question comes back to learning how to sleep well with the PAP machine. And for some folks, that's a steeper hill than it is for others.

Wish I could be sedated every night .

In all seriousness, it might be a decent idea to try something like Ambien or Belsomra or some other prescription sleep aid for a while. In my case, my sleep quality with PAP started to improve after I did some pretty hard CBT-I to work on "consolidating" my sleep cycles. But further improvement was only achieved after using Belsomra for about a year or two pre-pandemic.

I agree with all of the above - though I would wait with adding with adding sedation till I had tried the Lumis on EPAP=7 IPAP=9 for two weeks.

[palerider]

I'm not 100% sure, but I don't believe the Lumis 100 ST is a "S/T" machine, I believe it's what is called the "ST-A" here, which means it's Resmed's iVAPS non-invasive ventilator.

it does have a S mode (being used, T, ST, PAC and iVAPS modes.

The OP's Oscar data describes the machine as a Resmed S9 Lumis VPAP 100 ST. When I google that, the only links that come up are to the current AirCurve 10 VPAP ST machines.

Was there a VPAP in the S9 line?

For what it's worth, both a Lumis VPAP 100 ST and a Lumis VPAP 100 ST-A are listed on the Product Support Page on the Resmed web pages.

The whole S9 bilevel line was all "VPAP [something]" (the S9 version of AC10 VAuto was the "VPAP Auto"), I have a S9 VPAP Tx in the closet, and there was a Lumis Tx that was seen in hospitals, it was the do anything model. I'm believe that the "Lumis 100" was a 'elsewhere in the world version of the 'aircurve 10' line here.

I think it's reasonable to ask the OP to give us a picture of the machine, and ask what the REF number on the back is.

Also, I'm not sure that Oscar really knows what to do with Lumis models, because they're rare (in these parts) and may not be handling the names properly ("PAP mode BIPAP-S" is also suspicious.

[palerider]

One possible hypothesis for why you might feel better on the Lumis: Your body is so sensitive to the changing pressures on the AutoSet that your sleep is just simply more fragmented with spontaneous arousals when you use that machine. In that case, you might do much better using the Lumis in S mode with EPAP = 7cm and IPAP = 9cm.

My best guess is that you feel better when the numbers look worse because other than the under-treated OSA, your overall sleep quality is somehow better. My hypothesis would be you are among the group of PAPers who do better on fixed pressure simply because the auto adjusting pressure algorithm itself triggers some spontaneous arousals.

Try bumping up the EPAP to 7cm (which is where you other data indicates it needs to be) and your IPAP = 9cm on the Lumis while running in S mode. That might give you better AHI numbers, a smoother flow rate curve (i.e. less flow limitation) and still give you better sleep than you were getting on the AutoSet.

- Is it possible to also have UARS that fragments my sleep, but doesn't show up bc i wake before any FL och desats happen? Don't know what to do about that anyway as the treatment is pap...

[On my diagnostic test, the vast majority of my events were scored as something called "Hypopneas with arousal", which basically meant that, yes, I was arousing before the O2 desats happened. And yes, the treatment is still PAP.

So the question comes back to learning how to sleep well with the PAP machine. And for some folks, that's a steeper hill than it is for others.

Wish I could be sedated every night .

In all seriousness, it might be a decent idea to try something like Ambien or Belsomra or some other prescription sleep aid for a while. In my case, my sleep quality with PAP started to improve after I did some pretty hard CBT-I to work on "consolidating" my sleep cycles. But further improvement was only achieved after using Belsomra for about a year or two pre-pandemic.

I agree with all of the above - though I would wait with adding with adding sedation till I had tried the Lumis on EPAP=7 IPAP=9 for two weeks.

11/9, based on the autoset pressure, would probably be better, better oxygenation.