Need advice on ResMed S9 VPAP Adapt and high pressures

[Avatar]

I'm new to this, so please ask if some of my comments or questions don't make sense. Thanks in advance for any help.

A couple of months ago, following a second titration sleep study (my first one being about a year before that), I was moved from a ResMed VPAP S using IPAP 11 cm/H2O and EPAP 6 cm/H2O, which treated my OSA well, to a ResMed S9 VPAP Adapt with much higher pressures to treat CSA that surfaced after the OSA was treated. I’ve grown comfortable breathing with the new machine and the significantly higher pressures (please see below). But I continue to have trouble sleeping due to needing to wear my mask very tight to prevent significant leaks at the highest pressures, and rarely wear it more than 1.5 hours per night. I've tried several masks and I do think my current one has the best chance of working for me long-term if I can just learn to sleep while wearing it so tight.

I think I can adjust, but I think I might need to make the transition gradually, and I think my fancy new S9 VPAP Adapt can let me do that, as long as I understand what I’m doing. I’m considering lowering the pressures to where I can loosen the mask enough to sleep all night, then slowly increasing the pressures and tightening the mask over several nights while still wearing it most or all of each night. I'm considering adjusting the pressures on the S9 VPAP Adapt to be similar to my old pressures at first (which I realize will not effectively treat my CSA while at those pressures), then slowly increasing them, while monitoring my AHI on the S9's sleep report each morning to try to reach a good AHI while sleeping well with the mask all night.

So here are my questions:

1. Are the current pressures on my S9 VPAP Adapt, as set by my DME tech, consistent with the recommendation determined from my sleep study? The machine used for my sleep study was a "Respironics Omni Lab Advanced unit". The pressures recommended with it from the sleep study are:

Mode = AutoSV
Max Pressure = 25.0 cm H2O,
Max EPAP = 15.0 cm H2O,
Min EPAP = 5.0 cm H2O,
Max PS = 19.0 cm H2O,
Min PS = 9.0 cm H2O,
Bi-Flex = 3,
Rate = Auto BPM.

The settings on my S9 VPAP Adapt are:

Mode = ASV,
EPAP = 15.0,
Max PS = 10.0,
Min PS = 4.0,


2. Would the following settings on the S9 VPAP Adapt approximate IPAP = 11 and EPAP = 6 on the VPAP S? If not, what settings would?

Mode = ASV,
EPAP = 6.0,
Max PS = 5.0,
Min PS = 5.0,


3. In ASV mode, having Max PS greater than Min PS enables the S9 VPAP Adapt to increase pressure as needed to help eliminate detected CSA episodes, correct?


4. AHI = 0.0 is the goal, correct?


5. AHI = 5 or less is considered pretty good, assuming that I also feel good throughout the day, correct?


6. So if I’m wearing the mask all night and have a decent AHI, that is probably a better overall treatment than having a perfect 0.0 AHI where the mask is worn only for 1.5 hours and I am untreated for the rest of the night, correct?

Thank you!

[Pugsy]

6. So if I’m wearing the mask all night and have a decent AHI, that is probably a better overall treatment than having a perfect 0.0 AHI where the mask is worn only for 1.5 hours and I am untreated for the rest of the night, correct?

Correct. You are allowing more damage to happen by sleeping untreated than would be occurring even with an AHI much higher than 5.

I will leave your other questions to those that understand your machine.

Have you tried any mask liners to help with the leaks at the higher pressures? What mask are you using?
There are various mask liners available that many members use to help keep the mask from leaking so much at the high pressures you are needing. One of our forum members JohnBFisher uses mask liners at extremely high pressures and swears by them.

[Avatar]

Have you tried any mask liners to help with the leaks at the higher pressures? What mask are you using?
There are various mask liners available that many members use to help keep the mask from leaking so much at the high pressures you are needing. One of our forum members JohnBFisher uses mask liners at extremely high pressures and swears by them.

Thanks, Pugsy! No, I'm unfamiliar with mask liners, so I guess I should probably look into those. My mask is a Fisher & Paykel HC432, which goes under my chin slightly and has a foam insert to help the latex cushion hold its shape a bit better.

[Pugsy]

Links for mask liners. You can also try making your own from an old T shirt.
http://padacheek.com/PAC_Maskliners.html
http://www.remzzzs.com/Default.asp
http://quietusliners.com/

[Avatar]

Links for mask liners. You can also try making your own from an old T shirt.
http://padacheek.com/PAC_Maskliners.html
http://www.remzzzs.com/Default.asp
http://quietusliners.com/

Thanks, Pugsy! Wow, help is at hand already! I think I'll try the old T-shirt approach tonight, if my scissor skills are up to it, and then move on to some of the pre-made products if that doesn't work well enough for me.

By the way, I am still interested in answers to my other questions, if anyone is able to answer any of those. Even if the mask liners work well enough that I don't need to modify the pressures on my machine, I'd still like to understand the issues I outlined in my original post.

[JohnBFisher]

... JohnBFisher uses mask liners at extremely high pressures and swears by them. ...

Of course, that's when I'm not swearing at them!

The high mask pressures tend to make ANY mask leak. The other issue is that the ASV units change pressure VERY quickly (especially the Resmed units ... I have less mask leak problems with the Respironics ASV unit). A quick pressure changes does not allow the mask much time to "settle down" to the new pressure. So, it squeaks and squawks. And of course, sometimes it just gets rude and makes face fart sounds. I challenge anyone to sleep through that!

But overall, I find the mask liners do help. They don't prevent the leaks. But I find that by quieting them, I sleep through most leaks. If the leak is bad enough that the pressure is not effective, then I awaken - just as I did before therapy - adjust my mask and go back to sleep. So, while not perfect, I do sleep better with them than without them.

Hope that helps.

[NateS]

I'm new to this, so please ask if some of my comments or questions don't make sense. Thanks in advance for any help.

A couple of months ago, following a second titration sleep study (my first one being about a year before that), I was moved from a ResMed VPAP S using IPAP 11 cm/H2O and EPAP 6 cm/H2O, which treated my OSA well, to a ResMed S9 VPAP Adapt with much higher pressures to treat CSA that surfaced after the OSA was treated. I’ve grown comfortable breathing with the new machine and the significantly higher pressures (please see below). But I continue to have trouble sleeping due to needing to wear my mask very tight to prevent significant leaks at the highest pressures, and rarely wear it more than 1.5 hours per night. I've tried several masks and I do think my current one has the best chance of working for me long-term if I can just learn to sleep while wearing it so tight.

I think I can adjust, but I think I might need to make the transition gradually, and I think my fancy new S9 VPAP Adapt can let me do that, as long as I understand what I’m doing. I’m considering lowering the pressures to where I can loosen the mask enough to sleep all night, then slowly increasing the pressures and tightening the mask over several nights while still wearing it most or all of each night. I'm considering adjusting the pressures on the S9 VPAP Adapt to be similar to my old pressures at first (which I realize will not effectively treat my CSA while at those pressures), then slowly increasing them, while monitoring my AHI on the S9's sleep report each morning to try to reach a good AHI while sleeping well with the mask all night.

So here are my questions:

1. Are the current pressures on my S9 VPAP Adapt, as set by my DME tech, consistent with the recommendation determined from my sleep study? The machine used for my sleep study was a "Respironics Omni Lab Advanced unit". The pressures recommended with it from the sleep study are:

Mode = AutoSV
Max Pressure = 25.0 cm H2O,
Max EPAP = 15.0 cm H2O,
Min EPAP = 5.0 cm H2O,
Max PS = 19.0 cm H2O,
Min PS = 9.0 cm H2O,
Bi-Flex = 3,
Rate = Auto BPM.

The settings on my S9 VPAP Adapt are:

Mode = ASV,
EPAP = 15.0,
Max PS = 10.0,
Min PS = 4.0,


2. Would the following settings on the S9 VPAP Adapt approximate IPAP = 11 and EPAP = 6 on the VPAP S? If not, what settings would?

Mode = ASV,
EPAP = 6.0,
Max PS = 5.0,
Min PS = 5.0,


3. In ASV mode, having Max PS greater than Min PS enables the S9 VPAP Adapt to increase pressure as needed to help eliminate detected CSA episodes, correct?


4. AHI = 0.0 is the goal, correct?


5. AHI = 5 or less is considered pretty good, assuming that I also feel good throughout the day, correct?


6. So if I’m wearing the mask all night and have a decent AHI, that is probably a better overall treatment than having a perfect 0.0 AHI where the mask is worn only for 1.5 hours and I am untreated for the rest of the night, correct?

Thank you!

I hope the long-term ASV experts like JohnFisher will chime in soon for more experienced advice, but as a first-time S9 VPAP user since Dec. 2011 who was also diagnosed with Central sleep apnea, all I can say is that I am surprised at your HIGH settings compared to mine. EPAP is your threshold - floor - setting on the Adapt. While I need a PS Max of 15 and frequently go there, my EPAP has been at 5 since Dec. until I cautiously raised it to 6 last night for the first time. I can't imagine what an EPAP of 15 would feel like! Probably blow the mask right off my face. (If you can only keep it on for 1.5 hours a night, it sounds like that's what it's doing to you.)

At the other end of the spectrum, I don't understand why you would want to turn your Max PS all the way down to 5, which is lower than your threshold. If you keep in mind that EPAP is your floor and Max PS is your ceiling, this seems very strange unless you mistyped.

Don't you have a copy of your sleep study which includes a specific Rx from your doctor as to what your initial settings should be?

Best wishes,

Nate

[Namlehse]

I can't say from the point of VPAP, but from an APAP standard with a range of 16-20 cmH2O I have real issues finding a good mask to stand up to it. Even changes from 16-18 seem to make it seal differently. My doctor wants me to a CPAP of 19-20 but I just can't do it. I've settled on a range for now, pretty much all I can do. As you said, it's better to have some treatment if the other option is none.

I have two more masks on the way, a Forma and a Comfort Gell FF. Fingers crossed one will seal better lol..

[JohnBFisher]

... I'm new to this ...

So, welcome to the forum!

... A couple of months ago, ... I was moved ... to a ResMed S9 VPAP Adapt with much higher pressures to treat CSA that surfaced after the OSA was treated. I’ve grown comfortable breathing with the new machine and the significantly higher pressures (please see below). But I continue to have trouble sleeping due to needing to wear my mask very tight to prevent significant leaks at the highest pressures, and rarely wear it more than 1.5 hours per night. I've tried several masks and I do think my current one has the best chance of working for me long-term if I can just learn to sleep while wearing it so tight. ...

First. let me preview what I suggest - based on fighting with the previous generation of Resmed machines.

• You will want to register and record your equipment. That will make our answers more pertinent to your needs.
• Get the mask leaks under control. You will sleep better if your mask is quieter. That's why I recommend the mask liners.
• Get the Rescan software or Sleepyhead software to analyze how you are sleeping.

... 2. Would the following settings on the S9 VPAP Adapt approximate IPAP = 11 and EPAP = 6 on the VPAP S? ...

Yes, but I do NOT recommend that approach. The higher upper pressures allow the machine to act as a ventilator and sustain your breathing when you stop breathing (due to a central sleep apnea).

... 3. In ASV mode, having Max PS greater than Min PS enables the S9 VPAP Adapt to increase pressure as needed to help eliminate detected CSA episodes, correct? ...

Yes. It will keep the Pressure Support (the amount of addition pressure during inhalation) as low as possible, as long as you are breathing normally. But when the volume decreases (or the frequency drops too low), then it will increase the pressure upto MaxPS. It then acts as a ventilator and helps sustain your breathing when you are not breathing either as deeply or as frequently as you should. You should not disable this (by making them the same or dropping MaxPS too low), since it would not help you breathe when you stop breathing.

... 4. AHI = 0.0 is the goal, correct? ...

Not really. Feeling good is the goal. However, with time you will find that your AHI will drop toward zero.

... 5. AHI = 5 or less is considered pretty good, assuming that I also feel good throughout the day, correct? ...

AHI of 5 or less is considered normal (so better than pretty good). But otherwise you are correct. If you AHI is zero, but you feel like crud, then who cares?! So, both feeling well and having a lower AHI is important.

... 6. So if I’m wearing the mask all night and have a decent AHI, that is probably a better overall treatment than having a perfect 0.0 AHI where the mask is worn only for 1.5 hours and I am untreated for the rest of the night, correct? ...

That is correct. You need to wear the mask all night long to gain effective treatment. An AHI of 10, but you feel wonderful is better than an AHI of zero, but you feel horrible.

Hope all that helps.

Edited to change "respirator" to "ventilator". Sigh! Brain Fart this morning!!

[JohnBFisher]

... all I can say is that I am surprised at your HIGH settings compared to mine. EPAP is your threshold - floor - setting on the Adapt. ... I can't imagine what an EPAP of 15 would feel like! Probably blow the mask right off my face. ... At the other end of the spectrum, I don't understand why you would want to turn your Max PS all the way down to 5, which is lower than your threshold. If you keep in mind that EPAP is your floor and Max PS is your ceiling, this seems very strange unless you mistyped. ...

NateS, you almost have it correct. The odd thing about the ASV units is that the PS value is ADDED to the EPAP value to yield the IPAP value.

So, a prescription for a Resmed unit would show the EPAP value (in this case 15) and a MinPS and MaxPS value. The MinPS value is ADDED to the EPAP value to yield the lowest IPAP value. The MaxPS value is ADDED to the EPAP value to yield the highest IPAP value.

So, EPAP of 15, MinPS of 5 means that the EPAP is 15 and the minimum IPAP is 20.

And yes, those numbers are high. In fact, that high pressure might be triggering more central apneas. However, before we tinker with the pressure, it's a good idea to get those leaks under control. With that type of pressure ALL masks leak. 25cm H2O (the highest pressure of this unit) feels like a VERY stiff wind. It is a great way to exercise your muscles that support breathing.

But before anyone adjusts the pressure settings, it is wise to (a) get the Rescan or Sleepyhead software to analyze the sleep issues and (b) discuss it with your doctor. You need to follow a pretty strict process to be certain the changes you make have made a difference. You need to objectively prove that it helps. How you feel is important, but you then need to show numbers that justify the change. Did the AHI decrease? Did the number of apneas decrease? You get the idea.

[NateS]

Thanks for catching my error and correcting me on that, John.
I really appreciate it!
Nate

Avatar,

I would suggest that you might also find it helpful to review Page 15 of the Provider Manual for your Adapt where you will find the Descriptions, the Default Settings, and the Range for EPAP, Max PS, Min PS, Max Ramp, etc. for your machine.

Here is one of the many places from which you can download it:

http://ebookbrowse.com/resmed-s9-vpap-a ... d249905568

As JohnFisher said, do not assume that the settings on your prior machine are necessarily correct for the Adapt.

But we are still all in the dark as to what settings your sleep doctor prescribed???

Regards, Nate

[Avatar]

The high mask pressures tend to make ANY mask leak. The other issue is that the ASV units change pressure VERY quickly .... A quick pressure changes does not allow the mask much time to "settle down" to the new pressure. So, it squeaks and squawks. And of course, sometimes it just gets rude and makes face fart sounds. I challenge anyone to sleep through that!

But overall, I find the mask liners do help. They don't prevent the leaks. But I find that by quieting them, I sleep through most leaks. If the leak is bad enough that the pressure is not effective, then I awaken - just as I did before therapy - adjust my mask and go back to sleep. So, while not perfect, I do sleep better with them than without them.

Hope that helps.

That does help, John--thanks! I think underestimated the usefulness of the mask liners. I thought they were mostly to ease skin discomfort (which is still good, and may still be helpful for me). I will defintely try something. As you say, even if the leaks aren't stopped completely, if they're quieter and I get can back to sleep afterward, that would still be an improvement.

[Avatar]

• You will want to register and record your equipment. That will make our answers more pertinent to your needs.

Good tip, thanks.

• Get the mask leaks under control. You will sleep better if your mask is quieter. That's why I recommend the mask liners.

This does sound like it could be very beneficial, and I plan to try it. The leaks are the root of my whole problem: big leaks cause me to wear the mask very tight, which prevents me from sleeping long enough with it.

• Get the Rescan software or Sleepyhead software to analyze how you are sleeping.

[/list][/list]

I'll take a look at these, since I don't really know what they might show me, and I'd like all the help I can get. I'll need to get an SD reader first though.

... 2. Would the following settings on the S9 VPAP Adapt approximate IPAP = 11 and EPAP = 6 on the VPAP S? ...

Yes, but I do NOT recommend that approach. The higher upper pressures allow the machine to act as a ventilator and sustain your breathing when you stop breathing (due to a central sleep apnea).

Yes, I was considering these settings just as a starting point because those are tried-and-true settings for me that at least handle my OSA and where I know I don't feel awful during the day, just not as good as I think I can (but still much better than I feel now where I’m mostly untreated due to not wearing the mask enough.). But I would plan to move on from those settings to introduce treatment for the CSA with the goal of reaching my prescribed settings, or something close that gives me a good AHI.

Also, I thought I might see how much my CSA really was affecting me under my old comfortable settings, now that I can check my AHI. If I find that it's not really too bad, I might consider going back to my old VPAP S and barely-there Swift FX Nasal Pillows, although I don't really think that's very likely, since I'm sure I was prescribed my new treatment for CSA for a reason.

... 3. In ASV mode, having Max PS greater than Min PS enables the S9 VPAP Adapt to increase pressure as needed to help eliminate detected CSA episodes, correct? ...

Yes. It will keep the Pressure Support (the amount of addition pressure during inhalation) as low as possible, as long as you are breathing normally. But when the volume decreases (or the frequency drops too low), then it will increase the pressure upto MaxPS. It then acts as a ventilator and helps sustain your breathing when you are not breathing either as deeply or as frequently as you should. You should not disable this (by making them the same or dropping MaxPS too low), since it would not help you breathe when you stop breathing.

OK, good, I just wanted to be sure I understood. I don’t plan to keep MInPS and MaxPS equal for any long period of time, just long enough to determine what my AHI is when my OSA is treated but my CSA is not.

... 4. AHI = 0.0 is the goal, correct? ...

Not really. Feeling good is the goal. However, with time you will find that your AHI will drop toward zero.

Ah, good distinction. I’m a numbers guy at heart, but I need to remember that the numbers don’t tell the whole story for something like this.

Hope all that helps.

DEFINITELY! Thanks again!

[Avatar]

I would suggest that you might also find it helpful to review Page 15 of the Provider Manual for your Adapt where you will find the Descriptions, the Default Settings, and the Range for EPAP, Max PS, Min PS, Max Ramp, etc. for your machine.

Here is one of the many places from which you can download it:

http://ebookbrowse.com/resmed-s9-vpap-a ... d249905568

As JohnFisher said, do not assume that the settings on your prior machine are necessarily correct for the Adapt.

But we are still all in the dark as to what settings your sleep doctor prescribed???

Regards, Nate

Thanks, Nate! I did find that Clinical Guide previously, and the little bit that I feel I’ve learned about the S9 does come in large part from that book, along with other threads that I read in this forum. I had a heck of a time finding the guide online, however, so I’ll bet some other user will be thrilled that you posted that link!

You make a good point about not assuming that my old machine’s settings are appropriate for my new machine. They do seem wildly different, and I do know that the S9 does quite a bit more than the VPAP S, which presumably accounts for a lot the differences in settings.

I see I wasn’t clear about my prescribed settings, so I’m glad you pointed that out. My prescription is for the settings that I first posted (the 25/15/5/19/9 set of values) from the sleep study. The sleep study report says that “[t]he ASV best controlled respiratory events” at those values, and my doctor prescribed them without any changes. My doctor is not a sleep specialist, and probably felt that the sleep specialist who wrote the sleep study report had a better idea of what I needed than she, my doctor, did.

My first original question, about whether my ResMed S9 VPAP Adapt settings made sense for the prescribed settings from the Respironics Omni Lab Advanced, was sparked by a concern that maybe the DME tech who set up the ResMed S9 (or someone else, perhaps—I’m not sure who “translated” the Respironics settings for the ResMed unit) did not fully understand how to implement the settings from the Respironics unit, and may have used higher pressures than needed. I don’t really think that’s the case, but I’m really confused about the presense of a Min EPAP setting on the Respironics unit that doesn’t seem to be available on the ResMed S9 unit, so I thought someone here might understand that. But it does seem that both units’ settings have a maximum pressure of 25, and I think that the S9’s settings were probably determined to be what they are so that max pressure could be obtained.

Thanks again for the help, and please let me know if you have any more thoughts or advice!

[The Sheikh]

Does anyone have the clinical manual link for a ResMed S9 Adapt? (ASV) The one given in this thread has gone bad.

Thanks.

S