Smargie’s Therapy Thread...in Need of ASV Advice

[Pugsy]

If you are getting any sleep at all and we can't blame 95% of that ugliness on awake breathing false positives...then something is either wrong with your body's response to the therapy or maybe the machine itself.
Given what all you just told me...and if those are real asleep flagged events and you machines isn't screwed up....I wouldn't be using the machine until I had a nice chat with the doctor.
Something is horribly wrong somewhere.

Now if those are all awake breathing arousal false positives and you really weren't ever asleep...then they aren't real and we have a different problem.

Side note....Respironics machines can mess up with the flagging names sometimes. I have seen central apneas flagged as OAs...definite central but with the OA name plate on them.
I have an example somewhere but it's after 1 AM and I just woke up after falling asleep on the couch and I am off to bed....and showing you that example doesn't mean that you have the same thing going on...just means I know that the machine can mess up the names of the events.

And I do understand that doctors will roll their eyes if you go telling them that Pugsy on so and so forum said such and such.

If it were me and that was my report and I knew that most of the time that ugly was being flagged (whatever it is)...I wouldn't use the machine until I had a chat with the doctor. It scares the hell out of me and I wouldn't be doing it....if I had the same history as you just shared.
So you won't get any flack from me if you say you don't want to continue until you see the doctor....it's just a couple of weeks away.

If you want to try one more experiment....Try fixed pressure (set minimum to equal maximum) at 7 cm...turn Flex off if you can....and see what happens. I know totally against what you see the machine wanting to do or what people are going to recommend but this isn't working now....so I wouldn't continue doing it.
If you do have centrals popping up...apap mode is not the best mode to be using anyway.

[Jay Aitchsee]

If you want to try one more experiment....Try fixed pressure (set minimum to equal maximum) at 7 cm...turn Flex off if you can....and see what happens. I know totally against what you see the machine wanting to do or what people are going to recommend but this isn't working now....so I wouldn't continue doing it.
If you do have centrals popping up...apap mode is not the best mode to be using anyway.

FWIW, I generally agree with Pugsy's overall assessment and recommendation. I was going to suggest you try straight CPAP mode at 7cm with no Flex to eliminate pressure changes and the pressure pulses of the DreamStation which could be responsible for introducing CA's. However, not being familiar with the machine, I am not sure setting the Min and Max the same, or the mode to CPAP, will eliminate the Pulses. Further, I am unsure you have the ability to change the mode of your device (or the pressures, for that matter).

Pugsy, your thoughts?

SMargie, I assume the Doctor that referred you for the Sleep Study due to CO2 readings wasn't the Sleep Doctor, If not, you may want to inform her of the situation.

[Pugsy]

Pugsy, your thoughts?

All fixed cpap mode will change over using auto mode with minimum and maximum at 7 is turn off the flagging of Flow Limitations.
That's the only change with this Respironics machines. Pressure pulses still happen no matter what mode.
The test pressure probe spikey stuff won't happen though...which we can't really see happening on this last report because the machine was so confused trying to fix everything it never got to the point where it could say to itself "let me to my nice normal pressure probes because things seem calm" ..

That's why I suggest keeping auto mode but just changing minimum to equal maximum to mimic fixed mode....I want to keep the FL flagging turned on. Nothing else will change by going to fixed mode except turning off FL flags and while I know we can't do anything about FLs in fixed mode....I still want to know if they even happened. Just in case they do pop up. I doubt it in this situation but I can't be sure that going to a fixed much lower pressure will allow FLs or not.

The only thing you lose with fixed mode on Respironics machine besides the auto adjusting is FL flagging. You still get all those pressure pulses to help distinguish central from obstructive which may or may not be spot on with its accuracy. Most of the time it works properly but not 100% of the time. Let me go see if I can find the image of centrals being flagged as OAs for an example of the machine not flagging names accurately.

[Pugsy]

Here's an example of the machine calling a central....an OA
This person had a follow up sleep study which confirmed that these were indeed centrals and not OAs and his problem was central related and definitely not obstructive despite the large number of OAs being reported.
This is a rare situation...not common...but not impossible for it to happen when it comes to Respironics machines and the event classifications. They don't always get it right. I don't know that is what it going on with OP here...I just know that it might be happening...the machine might not be calling the flagged events accurately.

[Smargie]

I'm really exhausted (as Pugsy said, it's unclear whether I'm sleeping much at all!), so I am going to sleep without the CPAP tonight which I'm really looking forward to. I did find the instructions for changing the settings and will work on that tomorrow.

I would love to stop using the machine altogether until I have that chat with the doctor, but I'm worried about compliance. I think the DME people said that you have to be at least 70% compliant for the first 90 days or insurance won't pay for the machine. I suppose I could put in the minimum of 4 hours every night, and then take it off and continue sleeping. I often do that anyway because I'm tired of getting woken up by it for one reason or another. But then I'd also have to contend with not following the doc's instructions to keep at it, as well as continue feeling crappy.

I've also been worried that the CPAP is doing more harm than good, except for those lovely first 6 days when I was feeling better than normal. What to do, what to do?

[Pugsy]

Compliance requirements are for this machine only.
If you get a new machine the requirements will start all over anyway.
Plus there are ways of getting exceptions to that rule anyway.... and if you have used this machine for 21 nights out of 30 at least 4 hours a night...you have already satisfied any compliance requirements for this machine anyway.

I doubt it is 90 days that your insurance wants you to use the machine for 70% of the night....most insurance companies follow Medicare guidelines and its 30 days at 70% of the nights.
Did you actually get the 90 day number from your insurance or from the DME??? DMEs have been known to not tell the truth about compliance requirements just to put the fear of god in people so they will use the machine.

Actually what it means is 30 days.... and you have 90 days to meet that 30 day requirement of 70% of those 30 nights...or 21 nights with at least 4 hours of use.
If you have Medicare or your insurance goes by Medicare guidelines...it's 30 days out of 90 and you have to see the doctor face to face sometime between the 30 and 90 day of use.

[Pugsy]

Per that one graph where you showed the AHI results...21 days of use. I can't tell hours of use but you may have already satisfied that compliance usage requirement....you certainly have room to take a few nights off and not have it negatively impact the compliance even now.

[Smargie]

Doin' good on the chart work Marge. Now, how about zooming in and showing us a section of the Flow rate chart about 5 minutes in duration to include a couple of those CA? Do you have another mask? How do you feel about taping your lips? It doesn't look to me as if your leak rate is too high, although I'm not real good at reading DreamStation charts.


If indeed, these CA are being caused by air being forced out of your mouth, which I'm not certain they are, then tape or a full face mask might help.


In any event, see if you can zoom in on a section so we can see what it looks like.

Hi Jay...No, I don't have another mask and wouldn't be able to tolerate taping my mouth shut. I've attempted to zoom in on 5 minutes--I haven't really figured out how to zoom, but here's my attempt:

Flow Rate snip #15.PNG (18.13 KiB) Viewed 3229 times

Thanks for your input.

[Smargie]

Pugsy, it WAS the CME guy who said "the first 30 - 90 days are important for compliance". Didn't know they were so greedy. I think you're right about my having achieved compliance requirements by now. I will double check with my insurance to ease my anxiety. Here's a snip of my statistics so far:

Snip of CPAP Statistics.PNG (15.22 KiB) Viewed 3226 times

I'm so glad I found this website...I always find I learn a lot more by communicating via message boards with people sharing the same types of medical problems. Thanks for all your help.

[Chris8243]

I’ve ordered a chin strap and it will be here tomorrow. I’ll also get a scunci tomorrow. I went to the medical supply store yesterday and they said to first try the chin strap and that if that doesn’t work I’ll have to use a face mask. Seems like some of you go pretty far in order to avoid a full face mask.

The full face mask is not bad! I've been using Amara View, trying now to switch to Resmed F30. Both sit over your mouth and up to and under your nostrils, but not over the bridge of the nose. There are some that cover the whole bridge of the nose. I wear glasses and tried that kind but no go, can't wear glasses with that style.

So switching (or trying) a full face mask will not be the end of the world. There is also one called Dreamwear, headgear can accept nasal or full face style masks. I tried it and it wasn't for me, some people think it's the best

Clearly one size or shape does not fit all. Trial & error to find a good fit!

[Jay Aitchsee]

Hi Jay...No, I don't have another mask and wouldn't be able to tolerate taping my mouth shut. I've attempted to zoom in on 5 minutes--I haven't really figured out how to zoom, but here's my attempt:

That worked

To zoom:
*Left click and drag to highlight and zoom on a section
*Repeatedly left click on a spot without moving the cursor (right click to zoom out)
*Use the "up" keyboard arrow (down to zoom out, left and right to move)
*Use the slider under the events tab
*To quickly return to 100%, left click on "most recent day" symbol at top right of left panel or right click in label area of graph

Your 5 minute chart does indicate abnormal breathing and does appear (to me) there could be a mouth exhale component (sharp fall and quick rise to zero).
Because of the irregular breathing pattern and the time of night, I suspect that this selection may represent an aroused or awake state.

Due to the high number of CA you are experiencing and other possible medical issues, as Pugsy has suggested, I think the best course of action is to rely on your medical team and push for a rapid resolution.

In the meantime, trialing a fixed pressure as previously suggested and attempting to limit mouth exhale by chin strap and Scunci could be enlightening and/or beneficial.

[beautifuldreamer]

Last night I tried a soft foam cervical collar (not quite the right size) instead of my chin strap, and it worked much better than the chin strap for me!

My headgear from my mask stayed more in place as well (when I was using the chin strap over my headgear, both would get out of place during the night and was so difficult to get back in place) -

Also, I slept much better through the night and feel more rested than I have ever felt in quite some time

[Smargie]

Pugsy and Jay: Are these the settings I need to change? This is from the clinician's manual for my machine, Respironics Dream Machine CPAP auto.

snip of CPAP pressure.PNG (80.61 KiB) Viewed 3169 times

I'm having a hard time understanding EPAP, IPAP and a cmH2O pressure...

snip of CPAP cmH2O.PNG (116.01 KiB) Viewed 3169 times

[Pugsy]

EPAP and IPAP are mainly bilevel terminology and you won't see those setting choices available to you.

EPAP is just exhale pressure
IPAP is just inhale pressure
If you aren't using any Flex exhale relief at all then there would be no difference between inhale and exhale.
If you do use some Flex exhale relief then you are essentially creating a bilevel situation...so while not technically a bilevel mode...you have made the machine function like a bilevel mode machine. 2 distinct pressures...one for inhale and one for exhale.

When using apap mode...you set a minimum and a maximum and the machine can roam around between those parameters.

To make the machine use a fixed pressure in auto mode...you just set the minimum pressure to the same setting as the maximum pressure setting. It will let you do it...and in this case I would suggest 7 minimum and 7 maximum.
All the pressures are in cm H20....no matter if they are inhale and exhale. It's just the yardstick that is being used.

[Jay Aitchsee]

As Pugsy says, Centimeters of Water, (cm H20), is the unit of pressure used for this application. Similar to Inches of Mercury used to describe barometric pressure. In the instance above, CM H2O would be available in the CPAP mode and would be the fixed pressure.

Set mode to Auto (it should already be there and the Auto min and Auto max screens will appear). Set auto min to 7. Set auto max to 7. Set Flex to off.

Questions?