Suggestions for lowering CA's and Leaks

[TRzzz]

My wife is using a new ResMed Airsense 10 Autoset without humidifier (side cover installed in place of the humidifier). This machine replaced her S8 compact, which in addition to being a fixed pressure machine provides no data. She uses an F&P Simplus FFM with a fabric mask liner. (Without the liner she experiences some facial irritation from the mask alone.) Her lab sleep study was done in 2007, and the pressure on the S8 was set to 7.0. The pressure on the A10 is set to 7-20 with EPR off. I should note that she is on several pain meds for connective tissue disease and arthritis, and she wears a guard in her mouth to help with teeth grinding.

With the new machine and all the data it supplies, we are now able to see where she stands with her treatment. Her AHI is mostly in the range of 16 to mid-30's. Last night was a typical night:

Her main problems are the leaks and CA's. A couple of things to note:
1. The machine time after the 11:30 break was mostly awake, and the number of CA's shown is typical. Thus, her AHI score is being adversely affected by events while awake. Not much that can be done about that, I suppose ... or is there?
2. She has a number of mask leaks during the night, although interestingly she often has fewer events during those times than when not leaking. She's tried adjusting the straps and replacing the liner but to no avail.

We have found that nasal pillow masks don't fit her nose shape well, resulting in leaks and irritation, but often when using the full face mask she breathes with her mouth closed (as much as it can be closed with a teeth guard installed), whether awake or asleep.

Any thoughts and suggestions regarding how to eliminate the leakages as well as mask suggestions are appreciated!

(This is also my first time posting an image. Hopefully I've done it right.)

[raisedfist]

If her fixed pressure was 7 before , why not try 6 - 10 auto and see what kind of results she gets? And then hone in from there if needed.

It looks like her leak rate is hitting 120 or maybe even higher several times a night - has she followed the mask fitting guide from ResMed? I am surprised she isn't waking up from noise and air going all over the place.

The Simplus FFM is a good mask but that doesn't mean it's for everyone. The Airfit F10 and the Mirage Quattro are good as well.

[palerider]

If her fixed pressure was 7 before , why not try 6 - 10 auto and see what kind of results she gets?.

lower pressure would make the already too high obstructive apneas worse... bad idea.

[palerider]

(This is also my first time posting an image. Hopefully I've done it right.)

first, do not shrink the image, it makes it difficult to impossible to read the numbers.
there's no need to post both mask pressure and pressure, unless you've got an ASV or are zooming in on waveforms.
aside from that, you did much better than most.
guidelines for arranging and posting (read the third page for how to post the image better)
https://sleep.tnet.com/resources/sleepyhead/shorganize

Her main problems are the leaks and CA's. A couple of things to note:
1. The machine time after the 11:30 break was mostly awake, and the number of CA's shown is typical. Thus, her AHI score is being adversely affected by events while awake. Not much that can be done about that, I suppose ... or is there?

other than turning the machine off briefly to start a new session just before she goes to sleep... then ignoring the earlier sessions in sleepyhead, no.

2. She has a number of mask leaks during the night, although interestingly she often has fewer events during those times than when not leaking. She's tried adjusting the straps and replacing the liner but to no avail.

as you note, leaks are very bad, her base pressure is too low to handle the obstructive events.

based on the one pic, it doesn't look like her central apneas are caused by pressure, since they don't seem to track with the pressure changes.

she may need an asv, and a better fitting mask.

[TRzzz]

(This is also my first time posting an image. Hopefully I've done it right.)

first, do not shrink the image, it makes it difficult to impossible to read the numbers.
guidelines for arranging and posting (read the third page for how to post the image better)
https://sleep.tnet.com/resources/sleepyhead/shorganize

Yeah, I had read that stuff awhile ago ... then promptly forgot it. Also, I didn't use the screenshot command in SleepyHead but started with PrtSc on the keyboard, then cropped the image, then saved it, then erased the name up top, then had to resize it because the editing process bloated the image to over 1MB in size. What a waste of time. F12 in SH is a simpler starting point.

she may need an asv, and a better fitting mask.

When I read ResMed's info on the AirCurve line, I feel as if I'm reading something written for clinicians in obfuscatory language that us mere mortals aren't meant to understand, in particular, what factors mitigate in favor of any of the AirCurve machines versus one of the AirSense 10 Autoset machines. Given that the two lines look similar, it seems as if the only difference between the two is the software algorithms and the justification (read: pretense) to charge more.

Now that I've gotten that over with, the ASV model looks intriguing. Too bad it's so doggone expensive.

[palerider]

(This is also my first time posting an image. Hopefully I've done it right.)

first, do not shrink the image, it makes it difficult to impossible to read the numbers.
guidelines for arranging and posting (read the third page for how to post the image better)
https://sleep.tnet.com/resources/sleepyhead/shorganize

Yeah, I had read that stuff awhile ago ... then promptly forgot it. Also, I didn't use the screenshot command in SleepyHead but started with PrtSc on the keyboard, then cropped the image, then saved it, then erased the name up top, then had to resize it because the editing process bloated the image to over 1MB in size. What a waste of time. F12 in SH is a simpler starting point.

indeed, also, you can change your profile in sleepyhead by renaming the directory under 'Profiles" in the sleepyhead dir, change it to match your id here... or just crop it in imgur.

she may need an asv, and a better fitting mask.

When I read ResMed's info on the AirCurve line, I feel as if I'm reading something written for clinicians in obfuscatory language that us mere mortals aren't meant to understand, in particular, what factors mitigate in favor of any of the AirCurve machines versus one of the AirSense 10 Autoset machines. Given that the two lines look similar, it seems as if the only difference between the two is the software algorithms and the justification (read: pretense) to charge more.

Now that I've gotten that over with, the ASV model looks intriguing. Too bad it's so doggone expensive.

well, the aircurve's are just bilevel machines, and there's several different types, fixed dual pressure (S) auto changing dual pressure (vauto) there may be one with a backup rate for people with central apnea (ST) and then there's the ASV, at some point, there'll likely be an IVAPS machine (which is the S9 ST-A at this point).

I'd keep an eye out for a used one on craigslist, or shoot a note to grayghost4 and ask him to keep an eye out... his new hobby is finding machines on craigslist and other places.... when he's not out flying model airplanes.

as to your first question, the aircurve10S is the same as an elite, except where the elite is limited to no more than 3cm difference between inhale and exhale pressure (with EPR) the S can go to, (if you're a bit crazy) as much as 21cm... (4-25) on each breath. the Vauto is the same as the autoset in the same way. they also offer more tweaking of exactly how the pressure changes are handled.

the vauto and autoset change their base pressure over a period of minutes, whereas the ASV responds *breath by breath* with possibly very high IPAP pressure to ventilate you when you don't try to breath yourself... it's amazingly advanced.

[robysue]

If her fixed pressure was 7 before , why not try 6 - 10 auto and see what kind of results she gets?.

lower pressure would make the already too high obstructive apneas worse... bad idea.

The bigger problem right now is the number of CAs: The CAI = 19.4 while the OAI + HI = 10.4. So she's having almost twice as many CAs as obstructive events.

And it's worth seeing if a small reduction in min pressure combined with a reasonable max pressure might work better than the current range of 7-20, particularly since the titrated pressure was only 7cm.

In addition a much smaller pressure range may make a big difference in fighting the leaks.

[palerider]

If her fixed pressure was 7 before , why not try 6 - 10 auto and see what kind of results she gets?.

lower pressure would make the already too high obstructive apneas worse... bad idea.

The bigger problem right now is the number of CAs: The CAI = 19.4 while the OAI + HI = 10.4. So she's having almost twice as many CAs as obstructive events.

And it's worth seeing if a small reduction in min pressure combined with a reasonable max pressure might work better than the current range of 7-20, particularly since the titrated pressure was only 7cm.

In addition a much smaller pressure range may make a big difference in fighting the leaks.

I would agree with you, except for a few points:

1. there is no correlation between the pressure and leaks, at the point where the pressure was at its highest, the leak rate was acceptable, when pressure started coming down, there was a LL, but not certainly not the worst one.
2. there is no correlation between periods of central apnea and pressure, highest pressure, few centrals, 7cm pressure cluster of centrals.

perhaps I'm wrong but it seems that centrals are less stressful than obstructives, though one would have to examine the waveform to see whether breathing resumes gradually or with gasping after the centrals.

if there was any correlation between pressure and centrals or leaks, then I'd agree with you, but I don't see any correlation in that one chart.

a more important question is whether or not the OPs wife has been screened for heart disease, kidney disease, or other underlying neurological causes.

[TRzzz]

Thanks for diagnostic back and forth. As I noted in my original post, she has a high number of events during her awake time, and it may be due to the fact that she breathes with her mouth closed while she is awake. When she falls asleep, her mouth relaxes and opens up.

One of the machine setup variables is the kind of mask being used, whether pillows, nasal, or full face. Speculative question: is this just FYI information for the clinician, or does anything vary in the airflow or the event algorithm depending on the setting? As a test, I am considering changing the mask type in the setup to see if the machine behaves differently due to different expectations regarding airflow or breathing patterns.

[Julie]

You may end up confusing the machine... those designations are there for a reason and it's probably not the first (or second) place to start experimenting, especially with someone else's treatment.

[palerider]

One of the machine setup variables is the kind of mask being used, whether pillows, nasal, or full face. Speculative question: is this just FYI information for the clinician, or does anything vary in the airflow or the event algorithm depending on the setting? As a test, I am considering changing the mask type in the setup to see if the machine behaves differently due to different expectations regarding airflow or breathing patterns.

that information isn't recorded as far as I know.

there are differing opinions on what exactly that function does, but part of what it does is set thresholds for when the machine recognizes your mask is off, and shuts down automatically if smartstart is enabled. I believe that it also affects the pressure compensation algorithm to account for the different types of masks (full face masks have lower flow resistance than pillow masks, etc). the effects are minor.

best to just set the mask type correctly.

[Pugsy]

Mask selection menu on the machine is mainly for excess leak calculations. Depending on mask type selected a generic vent/intentional leak rate at whatever pressure is used to calculate excess leak only. It doesn't affect the algorithm or how the machine goes about doing it's job.
It just makes the reported excess leak more accurate. Full face masks typically have a higher vent rate than the other masks and if the wrong generic vent rate is removed the leak numbers may not be as accurate.

Use the correct mask selection so that you know the leak reported is fairly accurate.

[palerider]

Mask selection menu on the machine is mainly for excess leak calculations. Depending on mask type selected a generic vent/intentional leak rate at whatever pressure is used to calculate excess leak only. It doesn't affect the algorithm or how the machine goes about doing it's job.
It just makes the reported excess leak more accurate. Full face masks typically have a higher vent rate than the other masks and if the wrong generic vent rate is removed the leak numbers may not be as accurate.

Use the correct mask selection so that you know the leak reported is fairly accurate.

this is one spot where pugsy and I disagree, since *all resmed masks* have approximately the same vent amounts.

[Pugsy]

this is one spot where pugsy and I disagree, since *all resmed masks* have approximately the same vent amounts.

I know. That's why I said "mainly" and I am just going by what ResMed has always put in their literature about mask selection and leak calculations. I figure if they made a point to say it then it must have some impact or else they would do like Respironics does and make a WAG. ResMed mentions mask selection and leak calculations in the same breath...wasn't me.
You've read it too. Now do they have some other underlying thing going on????? they very well could and I am not saying you are wrong...I am just relaying what ResMed has said in the manuals.

[palerider]

this is one spot where pugsy and I disagree, since *all resmed masks* have approximately the same vent amounts.

I know. That's why I said "mainly" and I am just going by what ResMed has always put in their literature about mask selection and leak calculations. I figure if they made a point to say it then it must have some impact or else they would do like Respironics does and make a WAG. ResMed mentions mask selection and leak calculations in the same breath...wasn't me.
You've read it too. Now do they have some other underlying thing going on????? they very well could and I am not saying you are wrong...I am just relaying what ResMed has said in the manuals.

I know.... and I have seen that.... I still feel that the whole "used in leak calculations" was for older generations of machines that weren't as smart as the s9-a10 machines are.