Newbie- Could the machine be the problem?

[jeffreytt]

Quick synopsis- Been using a REMstar Auto A-Flex for a couple of weeks. The first week report showed pretty good results/numbers, (AHI- 3- Originally 21) but I was waking up every 2-3 hours. It seems when the pressure starts ramping up it doesn't stop until it wakes me up. I understand from reading the forums that's not uncommon when someone is starting out or particularly when you hit a different sleep stage. I started with Swift Fx mask and even though the health care place said the report was okay, (few leaks) they/I decided to try a ComfortGel mask for less direct pressure. Both masks seem fairly comfortable to me and I don't think the mask is the issue, but one thing I mentioned to them when switching the mask was the machine was starting to ramp up the pressure even if I was awake. They said this was not necessarily normal, but they had seen it happen before in other patients. They even tested the machine to make sure the pressure was the same as being reported, but in my mind that has little to do with the actual sensors/ramping up.

I realize a bad machine is probably the least likely problem since it's brand new, but I wondered if anyone could confirm whether the pressure should be building even before I'm asleep? For instance, last night I experimented and reduced the maximum pressure to 8 so the settings were 6-8. I was laying in bed trying to go asleep and checked the machine 30 minutes later and it was at 8. I just turned it off because right now I'm feeling better in the morning without it than with.

I'm also at a disadvantage since I didn't go to a full blown sleep study. I did one of the free home health ones followed by a more sophisticated home version (with oxygen levels) from the doctor I believe called Stardust. Since I have an extremely high deductible and I'm paying for this all out of pocket and there were not any other health issues, the doctor agreed to give me a prescription for a machine that's self titrating. I was thinking I could dial things in as needed. (And thankfully I also found this forum) I guess I'm just asking for advice on what to try and in what order. Would you try setting to a set pressure level and then adjusting based on nightly results? Should I continue trying to reduce the range of the original prescription? (5-15) Should I just bite the bullet now and pay for the full sleep study? Does it sound like the machine could be bad?

FYI- I have downloaded the Sleepyhead software. I am still trying to understand what everything means, but can certainly provide results as sporadic as they might be.

Thanks in advance. This forum has already been a huge benefit to me in the sheer amount of quality information available.
Todd

[Pugsy]

I doubt there is anything wrong with your machine but anything is possible.
I suspect the problem is the variable pressures associated with APAP mode.
Are you using the ramp feature at all?
If you are seeing an increase from 6 cm to 8 cm while you are awake then it may be something in the ramp setting. What was the minimum setting when you set max to 8 cm? And is ramp turned on?

If you could post one of your daily detailed reports from SleepyHead so we can see what the machine is for sure set and what is happening...we could offer more appropriate responses.

Mask model really shouldn't make the changes you are reporting. Let's see a report to get an idea what is going on.

Don't know how to post an image of your report? Here is how I do it with simple screen shots.

Open the image to full size so it is easily read.
I use Vista snipping tool to create a screen shot and crop the image at the same time.
Prt/scr key will also take a screen shot if using XP. If laptop is used sometimes the Fn key has to be pushed at the same time as the prt/scr key
I think windows 7 Home Premium has the snipping tool, Basic may not.

Once the screen shot is created save it in jpg format.
Upload the image to a host site. I use Photobucket it is free, there are others.
Once the image is uploaded then copy the ENTIRE IMG address. Be sure to include the opening and closing IMG in brackets. Paste that copied address into a post here.
Use the preview button. If you can't see the image try again because if you can't see it we can't.

[jeffreytt]

I couldn't get the scrolling window capture to work and fit all the charts on one screenshot, but let me know if you also need events or flow rate and I can take another capture. I've included two different days. The first is with the normal settings from the original prescription/SD card along with the first mask and the second is after I started tweaking the pressures down (and switched to the gel mask) just to see if that would work better. The actual "ramp" feature/button does work and it starts the pressure back at 4. Just one other note, the amount of variation from day to day seems insanely large to me. Some of the days the charts seem so bizarre I'm now sure how one would read them. I included Jan 9th at the bottom as an example. The AHI goes up from 1-5 without the pressure adjusting much and even appears to drop during that period?

January 12th


January 19th


Inconsistent Readings? Jan 9th

[Pugsy]

I suspect the variations in pressure in APAP mode are disrupting your sleep. It does that for some reason and obviously your machine wants to go higher to prevent the apnea events. Some of those pressure increase may be in response to leaks...or maybe the pressure increases trying to prevent the events caused the leak. The leaks aren't excessive..actually look worse on the graph than they are due to the scale used.

The machine won't increase the pressure unless it senses the need. If you are seeing a pressure increase shortly after masking up and you are sure you are awake then likely the machine is being fooled by something in your awake respiration that mimics an apnea event. The machine has no way to know whether you are asleep or not. It responds because it senses things and our awake breathing is much more ragged and uneven than we think it is.

If you notice...the nights with the higher maximum your leaks are more pronounced.. with the tight low range..leaks essentially non existent. It is possible that the leaks are causing you to awaken.
Leaks feed pressure...pressure feeds leaks...nasty circle develops.

I am unsure if the pressure going beyond 10 cm was due to events or leaks. We simply can't see deep enough to know for sure.

Did your doctor set this 5 to 15 range to get an idea where you needed to be or was this what the titration study advised? If it were me and I found the pressure changes disrupting...I would do like you did..limit the range but at a higher range. Obviously with 6 to 8 ...that 8 isn't sufficient. How about minimum of 6 and maximum of 10? Tighter range to limit possible disruptions and that 10 may be enough to prevent the events. Might need a little more..might not.. but would be a good place to start. You may not need that 15 cm maximum and until leaks aren't a possible contributing factor..don't let the machine chase leaks if it is doing so.

I think if you tighten the range it will lessen your sleep disruptions...You need to find a minimum pressure that is close enough to the pressure needed to prevent the events so the machine can get to that needed pressure quickly but not so quick it wakes you up and not with such a change that the change wakes you up. I think 6 min and 10 max would be a good starting point or 7 min and 11 max...if that disturbs your sleep...tighten it more. Some people do very well with a wide open range but some people simply don't.

[jeffreytt]

Thanks for the suggestions. I'll try a slightly higher/tighter range tonight. In terms of the initial levels he prescribed, because I didn't have a full blown sleep study there wasn't really pressure/titration settings for him to reference so I think that's why he used the range he did. I have a follow up appointment scheduled in another 4 weeks so I'm sure he was planning on looking at the results and adjusting, but I could really use some sleep between now and then. I'm running on fumes and as George Carlin once said, "the status quo sucks".

[Pugsy]

Ahh, then he likely won't care if you modify the settings a bit. Some people are truly super sensitive to pressure changes and you may be one of those people. Me? Heck I often saw 18 cm on my reports and slept right through it all. We are all different.

Hopefully a tighter range will lessen the sleep disruptions. It's a bad deal with the treatment for our sleep problems causes us to wake up all the time...really does make things a lot harder sometimes.

[jeffreytt]

Thanks for the suggestions. I went with 6-9 last night and while I still initially woke up after 3 hours, I was still able to get two good stretches of sleep and felt better than I ever have since I've been using the machine. (AHI 0.29) I did want to ask about the RERA number. As I understand from the glossary those are restlessness or near apnea events so I was curious whether my low AHI number would typically be considered good enough or if the RERA would still be considered worrisome?



In terms of the waking up, it looks like my flow rate changed 15 minutes before waking up. I'm guessing that maybe is a different stage of sleep but it looks like the pressures came down and then shot up within a couple of minutes and that's when I woke up, but I can at least see light at the end of the tunnel now and think I'm relatively close to getting the settings dialed in.

[Pugsy]

(AHI 0.29) I did want to ask about the RERA number. As I understand from the glossary those are restlessness or near apnea events so I was curious whether my low AHI number would typically be considered good enough or if the RERA would still be considered worrisome?

Your AHI is darn near perfect.
The RERA is also acceptable. You might find that this number will vary from night to night. Perhaps trend downward as you start sleeping more and getting used to all this stuff and not have as many sleep disruptions.