New User Confusion

[BSH392]

Hello to all. I am new here. You all do a great job, and I am happy to be on board. I am a newbie and have been using a DreamStation 2 for 30 days. (I actually used a Somnodent dental device for years, and thought that my Apnea was under control, but it turns out that I was completely wrong, notwithstanding a 3 year-old sleep study that showed good results). So I moved to CPAP.

I Learned about Oscar and the lack of compatibility as yet for the DreamStation 2. Will look to change to ResMed due to lack of Oscar compatibility. May also move to BIPAP after an upcoming titration/lab study at end of this month. In the meantime, just want to get your thoughts on my erradic AHI. After a home sleep study showing 40 AHI, and poor oxygen desaturation, I have gone on CPAP and began seeing 15 AHI for the first week. Moved to side sleeping and cut the AHI in half to 7.5 -- all on the DreamStation 2. Then, increased pressure and changed pillow resulting in a few days of 3.2 AHI and even 2.9. Now, AHI creeps up each night, back to 7.5 - 8.1 range. I am doing nothing different that I can figure out on my own, so I am frustrated. The Dream Mapper software shows 26 Clear Airway Apneas, 25 Obstructive Airway Apneas, and 11 Hypopneas -- resulting in an AHI last night of 8.2. This split of Apneas is typical each night (with about half being Clear Airway/Central Apneas). No major leaks, and mask fit seems good. Pressure is 7 minimum/14 maximum, and 90% pressure is 9, average pressure 8.4. Again, I am seeing pretty much these same numbers nightly. Any suggestions would be greatly appreciated. I will be doing the titration end of month, but I was optimistic that I had nailed it when I saw the 2.9 AHI. Now, that seems like a distant memory. Thanks again for all that you do.

[zonker]

I Learned about Oscar and the lack of compatibility as yet for the DreamStation 2. Will look to change to ResMed due to lack of Oscar compatibility.

welcome to the zoo!

you might want to reconsider on changing machines due to lack of oscar support. the oscar team has a presence here(blue dragon) and they are working on getting oscar to work with the dreamstation 2.

i'll let others deal with answering the rest of your post.

good luck!

[BlueDragon]

We are making great progress on adding support for the AirSense 11 since ResMed has apparently made only minor changes to the data files. The DS2 presents a much knottier problem as decoding the data is more difficult with the changes that Philips Respironics made to the data.

[BSH392]

Thanks for reply. Sleep test this week was not as hoped for. Confirmed severe apnea (home test was 40 AHI, and this laboratory sleep test resulted in 30 AHI), but they did not do any titration. So, now I must figure things out on my own. I currently have the (Oscar non-compatible) DreamStation 2. Most likely will replace it with ResMed purely for compatibility with Oscar. Maybe BIPAP is appropriate based upon my higher % of centrals, but it could be too early in the game. I am 30 days in to CPAP use, with average usage per night of 6.5 hours.

In the meantime, my AHI's jump around from a low of 3.2 to a 7.7 high. Most nights are at the higher range. Central Apneas are usually half to 2/3rds of the total apneas. Last night was: Total Clear Airway (Central) Apneas 28; Total Obstructive Apneas 17; Total Hypopneas 4. Device Mode is Auto CPAP; 90% Pressure is 10.0 cmH2O; Average CPAP pressure is 9.2 cmH2O; Min Pressure is 8.5 cmH2O; Max Pressure is 15.0 cmH2O. I have taken control of my settings, as I do not like the lethargy of the sleep docs and technicians. I am anxious to get things going, and they seem to have plenty of time. They also do not use Oscar and don't wish to do so -- a poor indication to me.

There does not seem to be any consistency from night to night insofar as whether I hit a 3 AHI or an 8 AHI. My mask is the AirTouch 30, and seems to be generally OK. I am using a cervical collar to avoid chin dropping. Until I am able to obtain an Oscar compatible machine, can you guys give me some guidance on 1- what you would do to my overall settings right now in order to move my AHI down with consistency and 2- any recommendations on machines.

Thanks in advance.

[ChicagoGranny]

1- what you would do to my overall settings right now in order to move my AHI down with consistency

Decision-making is difficult now because it is unknown whether the CAs are Centrals. If you are awake when these are happening, they are not apneas. The CPAP machine cannot tell whether you are awake or asleep. In a lab sleep study, you will be hooked to EEG leads, and it will be known whether you are sleeping or not.

Did you have a previous lab study? If so, did it indicate a tendency to Central Apnea?

2- any recommendations on machines.

You can get good advice on this after the results of your upcoming sleep study are known.

I am assuming you are not renting your current machine.

[Pugsy]

can you guys give me some guidance on 1- what you would do to my overall settings right now in order to move my AHI down with consistency

Unfortunately there's really not a lot that we can do for CAs/Centrals with your current machine unless maybe you are using Flex exhale relief and reducing Flex (or turning it off) might (stress the might part) reduce the centrals...and that's only if Flex is causing the centrals but to be honest I doubt it is. If it was you would likely have a much higher AHI with a primary central category being dominant.

How is your sleep quality? Waking often during the night or sleeping soundly for the most part?

When you give us the total numbers like you did for last night ...we also need to know the total hours used.
What might be a high number for 1 or 2 hours would be a nothing exciting number if someone used the machine 9 hours.

[BSH392]

Decision-making is difficult now because it is unknown whether the CAs are Centrals. If you are awake when these are happening, they are not apneas. The CPAP machine cannot tell whether you are awake or asleep. In a lab sleep study, you will be hooked to EEG leads, and it will be known whether you are sleeping or not.

Thanks so much for quick response. Not sure how to answer this. My brand new lab study (done this week) will be in my hands shortly, and I will try to answer this when I receive it. I suspect that some of it is during awake time, as it takes me a while to fall asleep.

Did you have a previous lab study? If so, did it indicate a tendency to Central Apnea?

Will try to respond once I receive the lab study copy.

2- any recommendations on machines.

I am assuming you are not renting your current machine.[/quote]
Yes, I am renting until I make final decision.

[BSH392]

Unfortunately there's really not a lot that we can do for CAs/Centrals with your current machine unless maybe you are using Flex exhale relief and reducing Flex (or turning it off) might (stress the might part) reduce the centrals...and that's only if Flex is causing the centrals but to be honest I doubt it is. If it was you would likely have a much higher AHI with a primary central category being dominant.

Thanks for quick reply. I have flex turned off.

How is your sleep quality? Waking often during the night or sleeping soundly for the most part?

Sleep quality seems better than before CPAP, but still awake 3-4 times per night. I have nocturia, which appears to be getting better as a result of CPAP treatment.

When you give us the total numbers like you did for last night ...we also need to know the total hours used.
What might be a high number for 1 or 2 hours would be a nothing exciting number if someone used the machine 9 hours.

Total hours used each night = average of 6.5 hours for the 30 day period. Last night was 6.6 hours of use with an AHI of 4.1 -- 20 Clear Airway Apneas; 6 Obstructive Apneas; 2 Hypopneas. 90% pressure was 9 and average pressure was 8.7.

Additional thoughts would be greatly appreciated. I will be talking to my DME about changing equipment, but don't know if I should be pushing for BIPAP, moving to ResMed Air Sense 10, or not, due to Centrals being a bigger percentage, and my current inability to get below 4 AHI. Overall, I am happy that my numbers appear to be coming down. I am still slightly tired at times during the day, but rarely nap.

I feel as if the "trial and error" support of my medical team is too sluggish. They do not use Oscar data, and do not exhibit the level of sophistication that I find on this forum; they also have lots of time to respond and want to wait weeks between setting changes. I want to receive more guidance from them, including pressure adjustment guidance, but feel that I am in this alone, so I am being proactive and doing it myself, with their limited input, and seeking the input of the "experts" on this forum.

[Pugsy]

You need to take a crash course in learning how to spot awake/arousal flagged events from asleep flagged events.
Watch all the videos here especially the bottom one.
http://freecpapadvice.com/sleepyhead-free-software
It talks mainly about central (CA) apnea flagging but in reality we can have arousal/awake flagged events in any event category.
Any flagged event that is related to arousal/awake breathing is what I call a false positive....it doesn't count in terms of evaluation of therapy itself because for anything flagged to matter you must be asleep.

You are new to cpap therapy and there is a high probability that some of those flags are awake/arousal related....if you aren't asleep they don't count....and you can't fix them with magic tweaks of the settings because the settings aren't the problem....the poor sleep quality and awakenings/arousals are the problem. You have to fix the sleep problem first.
Now high many of those flagged events are false positive....we don't know unless with do an up close evaluation of the flow rate or breaths.

And...it is normal to have a few central apneas that are real asleep apnneas anyway....entirely normal and they aren't a problem unless they are present in large numbers, cause desats or keep bouncing a person out of sleep.

Would a bilevel device help? Dunno but you don't need it based on pressure needs but I would suggest turning on Flex exhale relief because that in itself creates a bilevel situation.
Bilevel is nothing more than 2 distinct pressures being used...one for inhale and one for exhale.
Even your APAP machine can function like a bilevel device (in a limited capacity since the difference between inhale and exhale is limited) so it's worth trying.
The official bilevel devices....there are many different kinds that are bilevel for specific therapies...offer a bigger difference between inhale and exhale than you can get with apap/cpap machines.
You have to know what each different kind/model bilevel machine actually will do before wanting to go down the bilevel road just to maybe deal with centrals. Not all bilevel models do a darn thing for centrals.

Last night was 6.6 hours of use with an AHI of 4.1 -- 20 Clear Airway Apneas; 6 Obstructive Apneas; 2 Hypopneas. 90% pressure was 9 and average pressure was 8.7.

I would want to see exactly when those CAs were flagged before I started worrying about them. If they were flagged during periods of arousal/awake breathing they don't count and have to be removed from the calculations and if removed they don't need any sort of treatment other than try to fix the sleep arousal breathing part of what is causing them to be flagged.

[BSH392]

Thanks so much Pugsy. Will be looking further into all of your comments. BTW, we had an amazing Pug for 13 years. We are a pug family all the way around.

[Pugsy]

Thanks so much Pugsy. Will be looking further into all of your comments. BTW, we had an amazing Pug for 13 years. We are a pug family all the way around.

I have 2 rescue pugs right now (and 2 mixed breed rescues).
The black pug in my avatar...that is Sarge and I lost him a couple of years ago to a sudden heart issue at age 9. I still miss that little booger. He loved me to death. You know pugs....complete and unadulterated love and devotion.
My newest rescue...since Jan and this one is a challenge. She hates the other dogs (and cats) and is a real trouble maker...age 12 I guess now and not many teeth so she starts fights she has no chance to finish and already has lost an eyeball because of her attitude.
We are still learning house training and attitude training. Long story with this one.

About your machine quest....if you ever get a chance to try a ResMed apap.....try it.
I don't know that you really need bilevel at this point but you might like it.
So if you can try ResMed bilevel auto....not fancy high end bilevel though....try it also. Just because you don't "need" a bilevel due to pressure settings doesn't mean you won't find it helps you sleep better.
I am using the ResMed AirCurve 10 VAuto right now just because I like it....I don't have high starting pressure needs either.

[BSH392]

Pugsy - great that you do rescues! Such a wonderful thing to do. Pugs are amazing, and we were devastated when we lost ours after
13 years. Thanks for the further info on the ResMed equipment.

[BSH392]

Pugsy and anyone who cares to respond -- Here3 is the data from my lab sleep study this week. It shows the following:

304 minutes of total sleep time with total recording time of 458 minutes. Sleep latency was 31 minutes. Sleep efficiency was 66%
REM latency was 315 minutes;
N1 was 5.7% of total sleep time; N2 was 73.7% of total sleep time;
Sleep disordered breathing was more severe on back (156 minutes on back) with an AHI for that time period alone of 35.5;
Sleep disordered breathing was less severe on the side (252 minutes);
Overall AHI for entire sleep study was 14.0;
There were 71 total events consisting of 28 OSA's, 23 Centrals; 0 mixed apneas; and 20 Hypopneas; with maximum duration of 41 seconds
Respiratory Disturbance Index; (RDI) was 31.3 events per hour. (RDI=the average number of episodes of apnea, hypopnea, and respiratory event-related arousal per hour of sleep);
Sleep Saturation: Avg. 95%; Minimum 78%; 6.3 minutes below 88%;
Arousals: Arousal Index 18.9/hour; 96 arousals; 88 of those arousals (91%) were RERA (respiratory event related arousals).
Tracheal microphone revealed moderate-loud snoring; During sleep-disordered breathing, EKG revealed no significant changes;

So it does appear that I am dealing with real Centrals + OSA. I have a call with the Doctor this week. Any further advice would be greatly appreciated, including do I ask the doc for BIPAP? They did not do any titration on this laboratory study (as I had hoped that they would). They will certainly suggest another study with titration, but I am not doing it. I already have 30 days with APAP; and will likely be switching to ResMed this week (my Philips DreamStation 2 was not part of the recall, fortunately). My concerns have been mask leaks and AHI's that are erradic -- ranging from 2.9 up to 8 with no pattern. Oscar is currently not available to me on the Dream Station 2.

Thoughts on APAP/BIPAP and starting pressures? I am currently on Min. Pressure 8 / Max. Pressure 15.

Thanks.

[Pugsy]

We can't expect to fix the centrals with pressure tweaking on this model machine.
The best we can do is optimally deal with the obstructive apneas and hyponeas.
Now sometimes enough centrals go away with cpap/apap that further machine changes aren't needed....meaning people get lucky and don't need a different machine.

Usually if the central index (using cpap/apap) is less than 5.0 the docs won't want to do anything.

You are going to have to talk to your doctor about your options and what does he think needs to be done.

[BSH392]

I have a question for all, as my confusion continues due to newness at this game.

I have just tested the ResMed AirSense 10 Auto Set for a few nights, and am currently working with the Respironics DreamStation 2 (with a data card, but no Oscar integration).

In the meantime, why am I seeing fluctuations in AHI's that range from 2.9 to 10, with average of 6.5? If the APAP's (both Philips and ResMed showed the fluctuations) are supposed to tame the apneas, why would both these machines be able to do a good job on a few nights, a poorer job on other nights, and an average job overall on most nights (resulting in an average for the month of 6.5 AHI)? Yes, I have had mask leaks over a few nights, but both machines say 100% mask fit, and for the last month, the machines are showing 28 nights with no leaks. What I don't get is why the same pressures seem to work well on certain nights and not so well on others. I have moved to side sleeping, so that I can control apnea events, and have been diligent about not being on my back where my apnea index is significantly higher (per the lab study). Sure, it's possible that I slip to my back (my preference before CPAP), but I have never awakened to find myself on my back.

I realize that this is a basic question from a novice; but my confusion continues, and any thoughts would be appreciated.

Philips Respironics DreamStation 2
Mask: ResMed AirTouch 20
Settings: Minimum 7.5/Maximum 14.5