Central Apneas on Resmed Aircurve S11 VAuto

[chuck29]

I did read in forum that with my settings that PS 4 seemed low and it was recommended to try 5 or 6.

Who said that? What forum? I didn't see that recommendation at this forum. I suppose I could have missed it though.

I started using Sleep HQ for data along with OSCAR. So, I posted a bit over there as well. That was the only change I made from that forum.

[robysue1]

Hello All,

Resmed S11 Aircurve VAuto
IPAP: 18
EPAP: 10
PS: 4

I have been on Resmed S11 Aircurve VAuto for 3 weeks. I average ~4 AHI.
I feel worse than when I was on a broken S9 using Fixed and getting ~60 AHI.

and you also write:

Good thing is that my AHI is good, so I'm still holding onto, even though it's been 3 weeks, that it's still going to take more time to feel better, since I was dealing with 60 AHI for months on end.

Yes, I'm finding the front line folks and the RTs have no idea what they are talking about, and yes, folks at these forums know so much more!

So you've been using the AirCurve 11 for about 3 weeks, and you feel worse even though the AHI seems to be (close to) the correct range of being under 5 as compared to when you were using the broken S9 with a (machine reported?) AHI of around 60.

And you've also been doing some heavy duty dial wingin' in an effort to feel better. (More on that in a bit.)

As silly as it sounds, do you have any data from the broken S9's SD card to upload into Oscar or SleepHQ? It would be useful to compare a typical night on the broken S9 to what your current machine shows. In particular, what was the CAI on the broken S9?

And how long have you been using any CPAP/APAP machine? In other words, how long ago were you officially diagnosed with sleep apnea? Was your diagnosis based on an in-lab sleep test or a home sleep test?


You also write:

-Trigger set to Very High to address CAs:
I'm experiencing CAs when in VAuto mode. They average ~4 when Trigger is set to Medium. On advice of forum user, I set Trigger to Very High and can get CAs to 0. Just not sure if I should keep on Very High since this was not prescribed.

- S Mode
I used S mode (forgetting the reason why now, as I am too tired to think straight) and my CAs went to 45 with AHI being 55. One night of this and went back to VAuto as noted above.

So you've done dial wingin' in an effort to feel better by reducing the number of CAs. But the dial wingin' has included changing settings that you are not fully clear about in terms of how they affect therapy.

It appears that your VAuto Settings are more accurately described as:
Min EPAP = 10 (or perhaps 12 based on a post by ozij upstream)
Max IPAP = 18
PS = 4
Trigger = Very High (which seemed to help reduce the CAs as compared to Trigger = Medium)
Cycle = Medium

It's also not at all clear what settings you used in S mode. By chance did you use EPAP = 10 (or 12) and IPAP = 18? In that case, the PS on that disastrous night was a whopping 8cm, which could easily have triggered a boatload of (real) centrals.

And the data you posted for July 22 appears to have PS = 5.

What I want to address in this post is the Trigger setting. Trigger and Cycle control the way the AirCurve transitions between IPAP and EPAP by modifying the EasyBreath algorithm. In particular:

• Trigger controls how the machine transitions from EPAP to IPAP at the beginning of each inhalation
• Cycle controls how the machine transitions from IPAP to EPAP at the beginning of each exhalation

When you changed Trigger from Medium to Very High, you caused the machine to delay the transition to IPAP at the beginning of your exhalations---the Very High Trigger setting means that there has to be a (relatively) higher detected inhalation rate to cause the machine to go from EPAP to IPAP.

I'll be honest, I have no idea why this one change would reduce the number of CAs from a CAI of about 4 to a CAI of about 0. My own idle speculation would be that perhaps your body simply "likes" Trigger = Very High better because it somehow "feels" better. (In my case, I've set Trigger to Very High because that setting is more comfortable because it is less likely to cause aerophagia.)

My own feeling is that if your CAI is better with Trigger = Very High and you find it as comfortable or more comfortable than Trigger = Medium, just keep Trigger set to Very High.

As for the fact that a Trigger setting was not specified: I think the default script assumes that the Medium setting will be fine for everybody. I doubt the doc even specified a Trigger setting since you don't appear to have been diagnosed with central sleep apnea or complex sleep apnea based on an in-lab sleep test.

Finally you also write:

How was your sleep quality Monday July 22? Did you wake often?
How did you decide to use PS of 5? why?

On Monday 7/22, slept from 10:15 PM to 5:30 PM without waking up.
It was recommended on a forum to use PS of 5 to address OSA, but noted that it could increase CAs, which it in fact did.

So, tonight, PS back to 4. Also my Trigger was set to Medium, and giving me ~3-4 CAs. When on Very High, I was at 0 CAs. But, since I didn't feel any different, I moved back to Medium. Tonight I will be setting Trigger to High.

Thank you for the continued support!

Personally, I think you need to step back a minute and seriously consider what your goal is with the dial wingin'. Obviously your real goal is to feel better, but you are so focused on the dial wingin' efforts to reduce the CAI and/or the OAI that you keep changing them. And that makes it even harder to assess what is really going on with your sleep and why you're not feeling any better.

In other words it seems like you are hoping that there is some yet to be found set of settings that will allow you to wake up feeling drastically better.

But it's a process, and even with the exact same settings we don't sleep the same every single night.

My advice:

Pick a set of settings and commit to using them for at least 3 or 4 days. Unless there is a clear disaster, resist the urge to change the settings based on what happens to one piece of data on one particular night. Keep better track of how you are feeling in a way that is independent of looking at the data and allowing the data to influence how you think you feel during the day.

Then, tweak one thing at a time with the clear idea of what that tweak is supposed to address. Stick with the tweak for at least 3 or 4 days before deciding that it isn't working. Then tweak the next thing with a clear idea of what that tweak is supposed to address. And stick with it for several days. That's the only way you will be able to sort out which of all the things you've been changing is affecting the OAI, the CAI, and (most importantly) how you are actually sleeping overall and feeling in the day time.

[chuck29]

My advice:

Pick a set of settings and commit to using them for at least 3 or 4 days. Unless there is a clear disaster, resist the urge to change the settings based on what happens to one piece of data on one particular night. Keep better track of how you are feeling in a way that is independent of looking at the data and allowing the data to influence how you think you feel during the day.

Then, tweak one thing at a time with the clear idea of what that tweak is supposed to address. Stick with the tweak for at least 3 or 4 days before deciding that it isn't working. Then tweak the next thing with a clear idea of what that tweak is supposed to address. And stick with it for several days. That's the only way you will be able to sort out which of all the things you've been changing is affecting the OAI, the CAI, and (most importantly) how you are actually sleeping overall and feeling in the day time.

Thanks for this Robysue! Fantastic information. For some reason, I didn't see this reply before. I have printed out so I can reread. I will be responding. I like how you said to commit 3 or 4 days. I've been jumping because this fatigue is so debilitating, but you make sense.

I do want to send what I sent to Pugsy in another post a little bit ago, as some of it is applicable here:

Just some additional information that I find interesting:

Manometer:
I purchased a manometer, and found that my pressure was fine. I decided to check my old ResMed S9 VPAP S, which I was told was blowing at 8 per a supplier (I asked him to turn off ramp). Turns out, it is working fine. This is BiPAP set at 18/10. Note: I tested 18 pressure on both machines and S9 blows stronger. I put both in CPAP mode to test.

Central Apneas:
Now, my AHI was 60, with CAs in the 50s if I recall, on the S9, but I did not feel as bad as I do on S11 in VAuto. Also, manometer showed pressure is a bit better on the S9 (although S11 was showing above setting). I used S9 last night and changed Trigger from Medium to Very High. My AHI was 6.5 with CAs below 1.

S9 Noise:
Problem is that machine is very noisy now also the mask (even though it is the same I use on S11) was very noisy, so I only got about 5 good hours of sleep, so still not feeling wonderful, but maybe a tiny bit better.

S9 Ramp not working:
Another interesting note is that I have Ramp set to 30 minutes on S9, but within seconds its blowing 18/10. So if that is not working (machine has 22,000 hours on it), what else may not be...

Tonight, I will be using S11 in S Mode WITH Trigger set to Very High, want to see if feel ANY better.

[robysue1]

Just some additional information that I find interesting:

Manometer:
I purchased a manometer, and found that my pressure was fine. I decided to check my old ResMed S9 VPAP S, which I was told was blowing at 8 per a supplier (I asked him to turn off ramp). Turns out, it is working fine. This is BiPAP set at 18/10.

Please be more specific about the settings on both the S9 VPAP S and the AirCurve 11 VAuto:

On the S9 VPAP S: What are the IPAP and EPAP settings? Why was the machine tested at 8 cm?

On the AirCurve 11 VAuto: Are using VAuto mode? If so, there are three critical settings:

• Minimum EPAP
• Maximum IPAP
• PS

In S mode, there are only two settings: IPAP and EPAP.

There's a huge difference between S mode with IPAP = 18 and EPAP = 10 versus VAuto mode with Max IPAP = 18, Min EPAP = 10, and PS = 4 (or 5). So can you confirm which mode and the full settings for both machines?

Note: I tested 18 pressure on both machines and S9 blows stronger. I put both in CPAP mode to test.

Not sure what you mean here.
Some speculation on my part:

If your S9 VPAP S really is set to IPAP = 18, EPAP = 10, (with an implicit PS = 8cm), then once the ramp period is over, the machine will be blowing at IPAP = 18 on every single inhalation and the pressure will drop to 10 cm during every single exhalation.

If you are using the AirCurve 11 VAuto in VAuto mode with Max IPAP = 18 and Min EPAP = 10, then what is the PS setting? The default setting seems to be PS = 4; in that case, the AirCurve starts the night off with EPAP = 10 and IPAP = 14 = 10 + 4 = Min EPAP + PS. And the pressures increase or decrease based on what the machine sees in your breathing pattern. But all night long, IPAP = EPAP + 4, and so the pressures can range as follows:

• 14 <= IPAP <= 18 = Max IPAP
• 10 <= EPAP <= 14 = Max IPAP - PS

So assuming your AirCurve 11 VAuto is set with Max IPAP = 18, Min EPAP = 10, and PS = 4, then after the ramp period is over, the machine will be blowing at IPAP = 14 and EPAP = 10 until there is some reason to increase the pressure. So since the initial IPAP is 4 cm less on the AirCurve 11 VAuto, it makes sense that the S9's airflow would feel "stronger" at the beginning of the night: It has to blow harder to increase the pressure all the way to 18 cm instead of only 14 cm.

Central Apneas:
Now, my AHI was 60, with CAs in the 50s if I recall, on the S9, but I did not feel as bad as I do on S11 in VAuto. Also, manometer showed pressure is a bit better on the S9 (although S11 was showing above setting). I used S9 last night and changed Trigger from Medium to Very High. My AHI was 6.5 with CAs below 1.

Again, I'm still confused about what settings you were using on the S9 VPAP S. Earlier you said it was tested at 8cm. But you have also indicated the settings are IPAP = 18 and EPAP = 10. In S mode, which is the only mode available on an S9 VPAP S, that would mean you have a PS = 8, which is very unusual. And large enough to easily explain why you see so many CAs on the S9 VPAP S.

And it's not at all clear why changing Trigger from Medium to Very High on the S9 VPAP S with fixed IPAP = 18 and fixed EPAP = 10 would reduce the CAs from the 50s to less than 1.

Now if you used the AirCurve 11 VAuto in VAuto mode with Max IPAP = 18, Min EPAP = 10, and PS = 4 on the night where the CAI was less than 1, it's easy to see why the CAs would disappear, regardless of what Trigger setting you used: A PS = 8 (the S9 VPAP S setting?) is large enough to induce many people to blow off too much CO2 in each exhalation, which triggers the CAs, but a PS = 4 (the AirCurve 11 VAuto setting?) is small enough where most people do not blow off too much CO2 in each exhalation, and that means the CAs are not triggered.

S9 Noise:
Problem is that machine is very noisy now also the mask (even though it is the same I use on S11) was very noisy, so I only got about 5 good hours of sleep, so still not feeling wonderful, but maybe a tiny bit better.

S9 Ramp not working:
Another interesting note is that I have Ramp set to 30 minutes on S9, but within seconds its blowing 18/10. So if that is not working (machine has 22,000 hours on it), what else may not be...

Again, if your S9 is a VPAP S with IPAP = 18 and EPAP = 10, those are highly unusual settings with a huge PS = 10. Can you please confirm that the S9 is indeed an S9 VPAP S set with IPAP = 18 and EPAP = 10. Or is it a different S9 machine?

Tonight, I will be using S11 in S Mode WITH Trigger set to Very High, want to see if feel ANY better.

Again: You need to quit changing settings every single night in the hopes that something might miraculously work.

Do you have an idea of what you are doing by changing the AirCurve 11 VAuto to S Mode? And what IPAP and EPAP are you planning on using? Do you have an idea of what you are expecting to happen if you make this change?

Do you have an idea of what will happen if you change the Trigger setting to Very High? Do you have any idea of what you are expecting to happen if you make this change?


I'll end with this reminder of what you previously said:

My advice:

Pick a set of settings and commit to using them for at least 3 or 4 days. Unless there is a clear disaster, resist the urge to change the settings based on what happens to one piece of data on one particular night. Keep better track of how you are feeling in a way that is independent of looking at the data and allowing the data to influence how you think you feel during the day.

Then, tweak one thing at a time with the clear idea of what that tweak is supposed to address. Stick with the tweak for at least 3 or 4 days before deciding that it isn't working. Then tweak the next thing with a clear idea of what that tweak is supposed to address. And stick with it for several days. That's the only way you will be able to sort out which of all the things you've been changing is affecting the OAI, the CAI, and (most importantly) how you are actually sleeping overall and feeling in the day time.

Thanks for this Robysue! Fantastic information. For some reason, I didn't see this reply before. I have printed out so I can reread. I will be responding. I like how you said to commit 3 or 4 days. I've been jumping because this fatigue is so debilitating, but you make sense.

Given that you have two different machines, and one may have a very odd set of settings, you really need to pick one of the two machines (I'd say pick the AirCurve 11 VAuto) and one set of settings (tell us what they are) and NOT CHANGE ANYTHING for at least 3 or 4 days.

When your sleep is fragile, any change in setting can (by itself) cause a problem as it takes the body more than one night to acclimate to the way the machine now feels. If you change multiple settings every night (or switch between machines), you are not giving your body any chance to acclimate to the way the machine feels under the new settings.

My advice is to slow way down in the dial wingin'. And here's where I would start for the time being:

Use the AirCurve 11 VAuto set in VAuto mode with the following settings:

• Maximum IPAP = 18
• Minimum EPAP = 10
• PS = 4
• Trigger = Very High (based on things you have previously said)

Use these settings for at least 3 or 4 days without changing any of them. Don't get spooked into changing settings just because the AHI is a bit higher. Or you had a bit more trouble getting to sleep. Or you woke up too early and couldn't get back to sleep. Stick with these settings long enough for your body to acclimate to them---as in at least 3 or 4 days, maybe even longer.

Use a simple scale to track how you feel when you first get up in the morning and how well/tired/sleepy you feel during the day. Don't expect those things to change dramatically during a 3 or 4 day period.

At the end of 3 or 4 days (or longer) use the OSCAR/SleepHQ data and how you are feeling to make one carefully chosen tweak to the settings. Stick with the new settings for at least 3 or 4 days before making another carefully chosen tweak. (The only exception is if you have a clear disaster of a night; in that case go back to the previous settings and leave them alone for another 3 or 4 days.)

[chuck29]

(posting here and then will just respond to just one thread)

Robysue, I am still going to re-review what you sent and answer your questions, but wanted to just post here the following:

ResMed Aircurve 11:
Mode: VAuto
IPAP: 18
EPAP: 12
PS: 4
Trigger: Very High

Within these last few weeks, I was on these settings for 4 consecutive days.
Results:
AHI: ~3
CA: 0

Still felt crappy.


Last night, 7/26:
ResMed Aircurve 11
Mode: S
IPAP: 18
EPAP: 12
Trigger: Very High

AHI: 3.4
CA: .3

I will stay on this for the next few nights.
I am on trying S Mode because the S9 I used for years was in S Mode where I felt decent.

ALSO, I see that I am waking up earlier than I'd like, 6:00 AM, and trying to go back to sleep without much success. Bedtime will now be 9:30 PM EVERY NIGHT!

Thanks!

[ozij]

On the AirCurve 11 VAuto: Are using VAuto mode? If so, there are three critical settings:
Minimum EPAP
Maximum IPAP
PS
In S mode, there are only two settings: IPAP and EPAP.

ResMed Aircurve 11:
Mode: VAuto
IPAP: 18
EPAP: 12
PS: 4
Trigger: Very High

Within these last few weeks, I was on these settings for 4 consecutive days.

The above implies that the difference between your Inhale pressure and your Exhale pressure is always 4. On this setting, you will never have an inhale of 18 and a subsequent exhale at 12. NEVER. Because you yourself set the difference between these pressures the PS to 4.

Last night, 7/26:
ResMed Aircurve 11
Mode: S
IPAP: 18
EPAP: 12
Trigger: Very High

AHI: 3.4

While on this setting, you set the difference between inhale and exhale to 18-12 = 6. It will never be more that that, it will never by less that that. Your Inhale pressure will always be 18, your Exhale will be 12 the whole night, the difference will always, ALWAYS be 18-12 = 6

By changing both the mode from Auto to S and the difference, from 4 to 6 , you have no idea which of them has more impact on your therapy. Is it that you no longer have automatic pressure changes? Is it that the IPAP - EPAP difference is different 4 in VAuto mode, 6 in S mode? Nobody can tell.

Please watch the following video, https://youtu.be/ts9lNJ2g1IE explaining the settings on your machine.
Pay special attention from this point in the video https://youtu.be/ts9lNJ2g1IE?t=797 where The Lanky Lefty starts explaining the VAuto mode.

[chuck29]

Watching the video now, thanks...

[vandownbytheriver]

Don't forget, switching back and forth between vAuto and S mode will turn EasyBreathe on and off. I recommend using EasyBreathe ON for S mode, YMMV.

[chuck29]

Don't forget, switching back and forth between vAuto and S mode will turn EasyBreathe on and off. I recommend using EasyBreathe ON for S mode, YMMV.

Thank you for the reminder!

[chuck29]

At the end of 3 or 4 days (or longer) use the OSCAR/SleepHQ data and how you are feeling to make one carefully chosen tweak to the settings. Stick with the new settings for at least 3 or 4 days before making another carefully chosen tweak. (The only exception is if you have a clear disaster of a night; in that case go back to the previous settings and leave them alone for another 3 or 4 days.)

Hi Robysue, thank you again for this great advice. I'll post update when I can. I've stuck with settings, I see the point in that, it was that I was just so desperate to feel better so I could at least be at 50% of myself.

My biggest focus right now is getting to bed by 9:30. I've been tracking bedtime, awake time, and waking up in the middle of the night for months and I see I've getting about 6 hours and 45 minutes, 7 hours at best (I def need eight), so those spreadsheet numbers are staring me in the face. That plus the fact I've been getting those 60 AHIs for months prior, I'm making it my business to get 8 hours. Setup my tablet and phone to shutdown down ALL apps at 8:15 except Pandora and Kindle. Got about 5 days so far...

Thanks for the continued support,
Craig