APAP PR System One Remstar not working for me

[paultool]

Hi All,

Last June I ordered and received a new PR System One Remstar Auto CPAP machine with a heated humidifier after retiring my 10 year old Fisher Paykal HC220. I used the local Sleepmed outfit from whom I had obtained my earlier machine (I had been successful for 10 years with the HC220 at a straight pressure of 10 cm) and the tech there highly recommended the System One and had one himself. I had heard good things on this forum about the APAP machine and capabilities and wanted the latest technology. I also switched to a full face mask (Fisher Paykal Forma 432) since I have a deviated septum and also allergies which sometimes stuff up my nose and make it impossible to wear my old Vista Mirage nasal mask.

Now, I am sorry to say after almost 5 months of trying the new machine, I am having continual problems and am asking for help from others on the forum in understanding what is happening.

I tried running the System One on APAP for a few months at a 4 to 10 cm ramp, after a new sleep study confirmed that 10 cm was my desired pressure, and printed out the data (I ordered the Encore Viewer 2.0 and card reader for $111 from cpap.com). I never could get a good night’s sleep it seemed those first few months, and kept taking it off in my sleep. Yet I stuck with it thinking I was just getting used to the new machine and mask. I learned that removing the mask continually could be because the pressure was too low and I was gasping for air.

After several months and obtaining the software, I printed out the first report, and found out it was topping out at 10 cm for 90% of the time. So at the recommendation of the sleep technician at Sleepmed, I increased the pressure to 4-20 cm to see what would happen, and strange things began occurring. The machine was consistently trying to reach above 15 cm pressure, emitting bursts of pressure that woke me up. Even lying there awake, and obviously not having apnea events, the machine was still putting out bursts of high pressure, apparently unaware my breathing was normal while awake. The mask was leaking great guns at these high pressures too. It was very noisy and woke my wife up. It seemed out of control and I have never needed pressures above 10 cm with my old machine to sleep well and get the benefits of CPAP.

Thinking this cannot be right, I decided to try the straight CPAP settings of the machine, and set it for a steady 12 cm the last few weeks, trying it a bit above the 10 cm that I knew from years of earlier experience with the HC220 maching seemed to work for me. I say worked, because my pre-CPAP problems like frequent night urination and daytime tiredness stopped and I woke up feeling refreshed and never needed naps during the day.

I printed the report today at the straight 12 setting and it says I am still having AHIs ranging from 12 to 35 each night, and the mask leaks around my chin substantially. I think I can tighten the mask to reduce the leakage, but my wife says she can still hear me snoring even with the mask on, which has never happened before, and the report shows high levels of VS (vibratory snoring- readings 30-146). So I am back where I started years ago before I used any CPAP therapy at all. I am tempted to go back to my old machine, which is emitting funny noises but still works after 10 years of faithful service at 10 cm. Or order something else on Ebay or new just to get the problem solved.

Also, the humidifier on the System One does not seem to humidify, I run it on the next to highest setting, wake up every night with a dry mouth and have to remove the mask and drink water. With the old humidifier on the HC220, I could feel the moisture and never had to drink water for dry mouth. I am also getting up to urinate 4 or 5 times a night, like back before I started using CPAP due to the effects of apnea and brain oxygen desaturation on the bladder.

Have others had problems with the APAP settings going wild on them and with this machine? I thought at least the straight CPAP would work with it, but now I even wonder about that.

I am asking for help and will try whatever folks on here recommend. Since this is over my head, I also plan to seek out a local Dr. (third one I’ve tried in my area- most have never heard of APAP and no nothing about reading the data, etc) who I have heard is good with understanding of the technology. Problem is, he is not on my insurance but I will pay out of pocket to get this resolved.

Thanks for your help!

[danimal71]

I am a new guy at this but I believe that short burst of air is when it detects a hypopnea I believe. I get this too while I am awake and somewhat close to dozing off. It's kind of irritating to me.

Another thing I remember reading is that depending on how the machine is setup the machine will control the humidity based on the amount of humidity around the device. So you can set it at a 4 or 5 but it might not put out a higher level of humidity but make the temperature warmer. Frankly I have had mine at 5 before and the air coming in has never really changed temperature. I believe somewhere on the report through the software itr tells you what the average humidity was (1 - 5).

[Janknitz]

There are many issues here:

First, if your mask is leaking, you will not get consistent and reliable results with ANY CPAP/APAP machine. So you must get the leaks under control--sounds like the mask you are using is not the appropriate one for you.

Secondly, the way you set the APAP could be part of the problem. Your first setting was 4 to 10 and you kept taking the mask off in your sleep. This was probably occurring for two reasons, one is that the mask was LEAKING, and secondly that the setting was too low. If you are used to a pressure of 10 straight CPAP, you will feel like you are suffocating at 4 cm. No wonder you were taking the mask off!

Then you set a wide open pressure of 4 to 20. If you have a mask that doesn't leak, that pressure range is sometimes useful for self-titration. I say only "sometimes" because the wide open pressure range is slow to respond to apneas and may constantly wake you with pressure changes. It's better to set a narrow pressure range a few centimenters below and a few centimeters above your 90% pressure average if you know it, or an educated guess if you don't. However, with a leaky mask, you can't really do that, because the machine will eventually push up the pressures to try to compensate for the leaks. So the data you are trying to use to determine pressures is faulty from the very beginning. Furthermore, with a wide open pressure, even a mask that fits well without leaking at 4 cm is going to "blow" as the pressure increases into the teens. You are set up for failure from the get go.

It's NOT the machine's fault. Some people have a problem with the way the PR S1 tests airways with little puffs of air, and that can disturb sleep and cause discomfort. But I don't think that's your problem. I think that you need to work first on the mask. Get one that will not leak within a narrow range of pressures--I'd suggest you start with 8 to 12 or 13 cm since your titrated pressure was 10. Once you have a reliable mask, you can get reliable data to see if you need a pressure change.

Finally, no humidifier is going to be able to compensate for your leaky mask. Sounds like you are mouth breathing and the air is going right out of the mask, drying your mouth along its way out. Furthermore, by turning the humidifier UP, you are probably contributing to the nasal congestion which prompted you to get a FF mask to begin with.

I say your problem is not the machine. It begins and ends with the mask which is just NOT working for you.

[robysue]

paultool,

Seems to me that an obvious thing to try is setting the new machine in straight CPAP at 10cm (not 12) and turning off the C-Flex/A-Flex and ramp features. Give it a few days trial and then see what's going on with the data. And maybe try to find a different mask that feels more like your old Vista Mirage nasal mask.

Also---at the straight 12cm setting you say you are getting really bad AHI numbers (12--35). Have you looked at the more detailed data to see the breakdown of the events? Are there significant numbers of Centrals that may have started popping up with the higher pressure? Or is the rough percentage of OAs, CAs, and Hypopneas similar to your last sleep study?

If switching your System One to straight CPAP running at 10cm doesn't change anything for the better, then I think a trip to the DME may be in order just to make sure the System One really is working as designed.

[rosacer]

I agree 100% with Janknitz. Try what he says it will fix a lot of your problems. I have the PR System One and I saw a huge improvement when my new Dr adjusted my pressure range very closed. A wide pressure range is not good with the System One I think this machine reacts very fast and keeps the pressure going up and up if your maximum pressure is adjust too high and you have leaks, mouth breath or have acid refluxes. I have acid refluxes at high pressure, the solution was to limit the max pressure and 'voila' the problem is fixed.

[jonquiljo]

Janknitz and Robysue are spot on. They both have good and valid points. Try it - and post some data. I get you will end up working all of this out.

[DHC]

Hi All,

Last June I ordered and received a new PR System One Remstar Auto CPAP machine with a heated humidifier after retiring my 10 year old Fisher Paykal HC220. I used the local Sleepmed outfit from whom I had obtained my earlier machine (I had been successful for 10 years with the HC220 at a straight pressure of 10 cm) and the tech there highly recommended the System One and had one himself. I had heard good things on this forum about the APAP machine and capabilities and wanted the latest technology. I also switched to a full face mask (Fisher Paykal Forma 432) since I have a deviated septum and also allergies which sometimes stuff up my nose and make it impossible to wear my old Vista Mirage nasal mask.

Now, I am sorry to say after almost 5 months of trying the new machine, I am having continual problems and am asking for help from others on the forum in understanding what is happening.

I tried running the System One on APAP for a few months at a 4 to 10 cm ramp, after a new sleep study confirmed that 10 cm was my desired pressure, and printed out the data (I ordered the Encore Viewer 2.0 and card reader for $111 from cpap.com). I never could get a good night’s sleep it seemed those first few months, and kept taking it off in my sleep. Yet I stuck with it thinking I was just getting used to the new machine and mask. I learned that removing the mask continually could be because the pressure was too low and I was gasping for air.

After several months and obtaining the software, I printed out the first report, and found out it was topping out at 10 cm for 90% of the time. So at the recommendation of the sleep technician at Sleepmed, I increased the pressure to 4-20 cm to see what would happen, and strange things began occurring. The machine was consistently trying to reach above 15 cm pressure, emitting bursts of pressure that woke me up. Even lying there awake, and obviously not having apnea events, the machine was still putting out bursts of high pressure, apparently unaware my breathing was normal while awake. The mask was leaking great guns at these high pressures too. It was very noisy and woke my wife up. It seemed out of control and I have never needed pressures above 10 cm with my old machine to sleep well and get the benefits of CPAP.

Thinking this cannot be right, I decided to try the straight CPAP settings of the machine, and set it for a steady 12 cm the last few weeks, trying it a bit above the 10 cm that I knew from years of earlier experience with the HC220 maching seemed to work for me. I say worked, because my pre-CPAP problems like frequent night urination and daytime tiredness stopped and I woke up feeling refreshed and never needed naps during the day.

I printed the report today at the straight 12 setting and it says I am still having AHIs ranging from 12 to 35 each night, and the mask leaks around my chin substantially. I think I can tighten the mask to reduce the leakage, but my wife says she can still hear me snoring even with the mask on, which has never happened before, and the report shows high levels of VS (vibratory snoring- readings 30-146). So I am back where I started years ago before I used any CPAP therapy at all. I am tempted to go back to my old machine, which is emitting funny noises but still works after 10 years of faithful service at 10 cm. Or order something else on Ebay or new just to get the problem solved.

Also, the humidifier on the System One does not seem to humidify, I run it on the next to highest setting, wake up every night with a dry mouth and have to remove the mask and drink water. With the old humidifier on the HC220, I could feel the moisture and never had to drink water for dry mouth. I am also getting up to urinate 4 or 5 times a night, like back before I started using CPAP due to the effects of apnea and brain oxygen desaturation on the bladder.

Have others had problems with the APAP settings going wild on them and with this machine? I thought at least the straight CPAP would work with it, but now I even wonder about that.

I am asking for help and will try whatever folks on here recommend. Since this is over my head, I also plan to seek out a local Dr. (third one I’ve tried in my area- most have never heard of APAP and no nothing about reading the data, etc) who I have heard is good with understanding of the technology. Problem is, he is not on my insurance but I will pay out of pocket to get this resolved.

Thanks for your help!

Paul,

Others here have vastly more experience that me, so be sure to 'index' my suggestions accordingly. Nonetheless, here is what I suggest:

1. Focus on your mask first. If you have a mask that worked earlier - that is a known, and you should return to that at least for a while.

2. If the fixed pressure of 10 cmH2O worked before, use that again - at least for a while, and see how you do at that known pressure.

Both of these will make use of your positive experiences of years past - and should, hopefully, make it easier to begin the 'adjustment' process to a new 'platform' - and then on to 'tweaking' the new equipment to improve your therapy.

BTW - there is some information available about the differences in how APAP machines respond to various events. This *may* help explain a bit about the Respironics "bursts of pressure." In this white paper by DeVilbiss -- http://www.mediafire.com/?f1965ks6mjkjm02, beginning on page 18, they discuss some of the differences in manufacturer's device responses. They draw from an article ozij referenced a while back found here -- http://www.sleepreviewmag.com/issues/ar ... -09_02.asp.

I hope this helps.

[DoriC]

There are many issues here:

Great post Janknitz, it should be required reading! Thanks.

[chronic]

I love mine. It is set at 11 to 15. Had mine for 9 months. I agree with a lot that has been said. Tighten up your pressures and enjoy some good sleep.

[gandhimohatma]

I agree with the initial poster....i just got the system one and it seams like a scam machine. It was set to auto cpap by the technician but it doesnt do "auto". Basically it slowly ramps up to 90% pressure by itself with no regard for howyou are breathing. I was lying awake and intentionally stopped breathing...trying as hard as i could to make the machine increase pressure....but it stayed low.....then as im still awake breathing normally the machine starts blowing at 90% pressure. Its really only a cpap machine. I do like the aflex setting though...but i really need to do something about this since insurance refused to pay for a sleep study and the machine goes to 90% which is 13.5cm but i never had a study to show this is my correct pressure. This is why the original poster got higher readinds when the range was increased...because the machine always goes to 90% of the max pressure you set.

[Pugsy]

because the machine always goes to 90% of the max pressure you set.

No it doesn't ALWAYS go to 90% of whatever the max is. When I used that machine my max was 20 and occasionally I would see 18 cm but my overall 90% pressure over an entire year was 12.5 with the max at 20.

I was lying awake and intentionally stopped breathing...trying as hard as i could to make the machine increase pressure....but it stayed low....

No air moving while awake..just holding your breath...the machine won't increase the pressure because the airway is already open.
It won't/can't increase the pressure when the airway is not blocked by collapsing airway tissues.
So the no increase in pressure is exactly what the machine is supposed to do when there is no air flow and the airway is open.
Collapse of the airway tissues occurs when we relax while in sleep. It won't happen while awake.

This machine will respond to warning signs of an impending collapse of the airway with an increase in pressure..that's its job.
Those warning signs are Flow limitations and snores. If you are continually seeing really high 90 % pressures nearly at the max then you likely need higher pressures. Maybe the minimum needs to be adjusted so the airway is held open better and maybe prevent some of those warning signs.
See this thread. Older thread with older machine but the concept remains the same. Note the difference in 90% pressure.
viewtopic.php?f=1&t=39869&st=0&sk=t&sd=a

[khauser]

I agree with the initial poster....i just got the system one and it seams like a scam machine. It was set to auto cpap by the technician but it doesnt do "auto". Basically it slowly ramps up to 90% pressure by itself with no regard for howyou are breathing. I was lying awake and intentionally stopped breathing...trying as hard as i could to make the machine increase pressure....but it stayed low.....then as im still awake breathing normally the machine starts blowing at 90% pressure. Its really only a cpap machine. I do like the aflex setting though...but i really need to do something about this since insurance refused to pay for a sleep study and the machine goes to 90% which is 13.5cm but i never had a study to show this is my correct pressure. This is why the original poster got higher readinds when the range was increased...because the machine always goes to 90% of the max pressure you set.

This machine works great for me. I think the test you attempted is not valid. CPAP is not designed to increase the pressure like that. I've done this exact test and the machine will send the pulses people have mentioned. It does this to determine if the event is an obstructed airway or something else. If you continue not breathing it flags an obstructed airway and SLOWLY ramps the pressure up (ramp is not a perfect word because xPAP's often have a ramp feature which is NOT what we are talking about). I don't think there are any machines that upon detecting obstructions RAPIDLY increase the pressure.

The best way to see how it is doing is to read the graphs it can produce (ie, with SleepyHead).

All that said, if you are not happy with the machine you could try swapping it out for a different system. I don't think you'll find one that meets the above expectation, though.

Edit: Upon re-reading the thread, Pugsy's answer is way better than mine. Nonetheless I stand by my statement that machine don't rapidly increase the pressure.

[gandhimohatma]

my bad, i spoke to soon before i tried any further testing or reading. I am the misinformation highway....when simulating snoring, the machine does increase pressure, and when i stop simulating snoring, it goes down. Also i read briefly about the algorithm, that it isn't instantaneous, that it looks for best pressure for you etc. I'm not sure why if i stop breathing on purpose as a test it doesn't seam to increase, who knows, i'm satisfied it's working. But my best advice is to disregard my previous post, sorry.

[archangle]

I'm not quite sure of the exact details, but the machine seems to be pretty hard to fake apneas on. One problem is that it seems to wait about a minute after the apnea before it does anything. I also had more luck faking it if I started inhaling again "explosively" with a burst of air, the way you would if your airway was blocked and suddenly opens.

I used mine for months and and it would adjust pressure up and down and not get anywhere near the maximum. I tinkered with the pressure manually a lot and it seems to have found a pretty good choice of pressure. I did decide to increase my minimum pressure above where the machine "wanted" to go.

Any of the machines will "run away" on some patients and you may need to adjust the minimum and maximum. Thats one of the reasons you need a fully data capable machine.

[DoriC]

If you hold your breath to stop breathing the machine could very well think you're having a central or clear airway and these machines do not respond to those events with increases in pressure.