New-ish User, Terrible Results Taking a Nap

[lynninnj]

What is a bit frustrating is that I really don't understand much of this. My sleep doctor pretty much just gave me the test, confirmed my 33 AHI, then the machine arrived a few weeks later. When I first got it I didn't even know I needed to keep my mouth closed and had to figure it all out on my own. Bad on them, but they're local and take my insurance and I didn't need to wait 9 months to get my first appointment so I went with it.

I don't know how to change the pressure on my device. I don't really know what the ramp up time is supposed to mean, or if I want it short or long. It's pretty much just using the defaults the device shipped with. I didn't choose to use the auto ramp, and I haven't slept without it, and while that is a feature I can change, I don't really know what it should be set at so it's just on Auto.

I'm open to any advice, and yes I understand nobody are doctors, but right now I'm basically just using my machine on Auto / default settings. And it sounds like I should be tweaking something, somewhere. Presumably the pressure was set at the factory based on info my sleep doctor gave them, but if it can be changed, I don't see any options in the menu to do so.

It sounds like my minimum is set at 4, but should be set to 8, because with auto-ramp enabled, I basically zoom past 4, 5, 6, 7 and quickly slam right into 8. So I should be starting at an 8. The auto ramp sounds like it is supposed to prevent 8psi of air blasting into my nose the second I turn the thing on. But it also sounds like I DO want to avoid using auto ramp for a reason I don't quite understand? Thanks again for any help.

When you press both icons on machine and hold them ( options and sleep view) the screen turns grey and goes into clinical mode. You can change from there.

I used to have 15 min ramp and a good compromise is to set on 5 or turn it off. I like having five minutes where I know it turned on and I can get settled in and will not show any markings of any events during that time. I am not bothered when it goes up to my minimum which is seven 5 min later. You can set ramp pressure on 5-6 (any pressure you want) if you wanted so it’s more gradual. I find this helpful because I can make mask adjustments while I am laying down and five minutes isn’t long so I don’t have to lie awake restlessly. If you fall back to sleep in the middle of the night within that five minute period of time it may not mark an event and you may be seeing pressures Whipping up in a hurry. I wouldn’t worry about that though right now. That’s what I like about the five minutes. I probably am back to sleep after five minutes after trip to the bathroom.

Ramp is a kind of minimum and it gives settle in time but minimum is a different setting and should probably be around 8 as mentioned.

Raising your minimum will help.

[robysue1]

I don't know how to change the pressure on my device. I don't really know what the ramp up time is supposed to mean, or if I want it short or long. It's pretty much just using the defaults the device shipped with. I didn't choose to use the auto ramp, and I haven't slept without it, and while that is a feature I can change, I don't really know what it should be set at so it's just on Auto.

To change the pressure setting, you have to get into the clinical menu. And that means you need the clinical manual instead of the users manual that they probably gave you with the machine.

Fortunately, it's easy to find the clinical manual. Here's a url for it: https://media.resmed.com/sites/3/202106 ... ER-ENG.pdf

I'm open to any advice, and yes I understand nobody are doctors, but right now I'm basically just using my machine on Auto / default settings.

Actually it sounds like the doc just ordered the machine to be set to factory defaults. Maybe the idea was to let the machine do the so-called titration at home rather than putting you in a lab with a tech manually adjusting pressures while watching your data.

If you have a follow-up appointment scheduled with the doc (or a PA), then they might look at the data from the machine and then rewrite the script. But the rewritten script could easily be for "CPAP at n cm" where n is equal to your 95% pressure level in the APAP data.

And it sounds like I should be tweaking something, somewhere. Presumably the pressure was set at the factory based on info my sleep doctor gave them, but if it can be changed, I don't see any options in the menu to do so.

That's because the medical community and Resmed do not want patients changing the therapeutic settings. And so the clinical menu is "hidden" from patients. But note: the hidden menu is not particularly well hidden---i.e. it's easy to access once you know how to do it. So read the Remsed Airsense 11 Clinical manual for details about how to get into the clinical manual and how to change the pressure settings.

It sounds like my minimum is set at 4, but should be set to 8, because with auto-ramp enabled, I basically zoom past 4, 5, 6, 7 and quickly slam right into 8. So I should be starting at an 8. The auto ramp sounds like it is supposed to prevent 8psi of air blasting into my nose the second I turn the thing on.

Yes, and yes.

The question you need to answer is: Does starting at 8cm actually bother you and your nose?

Plenty of people find out that 8cm is not really any "harder" to start at than 4cm is. And plenty of people actually find starting at 7 or 8cm is easier than starting at 4cm because they subjectively feel there's not enough air coming through the mask at 4cm.

But it also sounds like I DO want to avoid using auto ramp for a reason I don't quite understand? Thanks again for any help.

Whether you want to avoid using the auto ramp altogether or just increase the starting ramp pressure for the autoramp is for you to decide.

The reason ozij has suggested turning the autoramp off appears to be two-fold:

1) Once the autoramp ends, your pressure quite quickly zooms way up. If the machine is correctly determining when you are getting to sleep, then the machine clearly thinks your breathing becomes unstable sleep breathing just as soon as you fall asleep, and that pretty much means you're at some risk for real events sneaking through the CPAP defenses just as soon as you fall asleep.

2) It's not clear the autoramp is making it easier for you to fall asleep.. If the machine is incorrectly determining when you are getting to sleep, then it may be identifying parts of your normal wake breathing as unstable sleep breathing and ending the ramp before you actually fall asleep. And then the questions become: Does that sudden increase in pressure keep you awake? Or does it wake you back up just as you are dropping off to sleep? And then do you finally actually get into a sound sleep after the pressure finally gets up to the 8-10cm range?

As ozij says, we usually recommend that a PAPer change one thing at a time. But right now your min pressure is at 5cm and the beginning autoramp pressure is at 4cm. Changing the min pressure up to 8cm, but leaving the autoramp on is not going to change those sudden increases in pressure right after the autoramp goes off. And that's why she's suggesting doing two changes at once.

On the other hand, if you want to still use the autoramp feature, but start at a higher pressure, then you are going to have to change the min pressure anyway: The beginning ramp pressure has to be strictly lower than the minimum pressure setting---otherwise, there's no need to "ramp" the pressure up.

If you are worried about going without the autoramp after you increase the min pressure to 8cm, you could choose to increase the beginning ramp pressure to something like 6cm.

Experiment while you are awake: See if you can comfortably breathe while lying down with the machine blowing at 8cm for at least 10 or 15 minutes. If you can do that, you can most likely turn the ramp off and just use 8cm as your minimum pressure setting. But if you can't do that, then see if you can comfortably breathe while lying down with the machine blowing at 6cm for at least 10 to 15 minutes. The idea is to set that beginning ramp pressure as high as you can while still being comfortable when you are trying to get to sleep.

[ozij]

Experiment while you are awake: See if you can comfortably breathe while lying down with the machine blowing at 8cm for at least 10 or 15 minutes. If you can do that, you can most likely turn the ramp off and just use 8cm as your minimum pressure setting. But if you can't do that, then see if you can comfortably breathe while lying down with the machine blowing at 6cm for at least 10 to 15 minutes. The idea is to set that beginning ramp pressure as high as you can while still being comfortable when you are trying to get to sleep.

In order to do that, put the ramp on timed, not on auto. The internet swallowed the post in which I explained the difference....

The auto ramp is a new feature, attempting to keep the machine "twiddling its thumbs" doing nothing as long as it thinks you're awake (up to 30 minutes, I think). In your case, it doesn't seem to be too good at discovering when you're awake and when you're asleep. Don't take it personally all those auto algorithms work for a majority of the population, but some of us fall through the cracks.

By the way, it's not psi, it's cm/H20.

[decker12]

Experiment while you are awake: See if you can comfortably breathe while lying down with the machine blowing at 8cm for at least 10 or 15 minutes. If you can do that, you can most likely turn the ramp off and just use 8cm as your minimum pressure setting. But if you can't do that, then see if you can comfortably breathe while lying down with the machine blowing at 6cm for at least 10 to 15 minutes. The idea is to set that beginning ramp pressure as high as you can while still being comfortable when you are trying to get to sleep.

I will do exactly this, it sounds like a great way to determine both my minimum pressure setting and determine if I really need the auto-ramp or not. I honestly don't know if I need auto ramp - it was just the device defaults, and I really didn't know what it did other than "slowly increase air pressure" which sounded good for a newbie, but I didn't base that decision on any proper explanation. I did not struggle with the device for weeks until I found the option to enable auto-ramp and then suddenly I was able to sleep fine.

I'll use the clinical setup area to set it up as you noted above - get home, pretend it's bedtime, set it to 8cm, leave auto-ramp turned on, and see if I can breathe normally and relaxed like I was going to fall asleep. If it's not a problem, turn off auto ramp and try to sleep tonight. With ramp turned off, I'll get the full 8cm immediately when I turn it on and I'll run that for a couple of days and see how I feel.

Should I be concerned that 8cm as a minimum is considered good or bad? Or is the air pressure just something everyone has to experiment with until they find the balance?

[ozij]

Should I be concerned that 8cm as a minimum is considered good or bad? Or is the air pressure just something everyone has to experiment with until they find the balance?

The latter.
Way back when - pre pandemic - people used to have their pressure titrated. That is: they slept in a sleep lab, connected to all kinds of monitors, and a sleep tech would change the pressure on the machine to see how their breathing responded to different pressure levels.

And even then, many of us discovered that under those sleep conditions we didn't get the correct pressures scripted. You'll have to experiment to find the balance, and we're here to help.

[Dog Slobber]

The auto ramp is a new feature, attempting to keep the machine "twiddling its thumbs" doing nothing as long as it thinks you're awake (up to 30 minutes, I think). In your case, it doesn't seem to be too good at discovering when you're awake and when you're asleep. Don't take it personally all those auto algorithms work for a majority of the population, but some of us fall through the cracks.

By the way, it's not psi, it's cm/H20.

AutoRamp is not a new feature, it's been around since the inception of the AirSense 10 and it does not *just* switch from ramp mode to therapy mode when it thinks you're asleep or when 30 minutes goes by.

AutoRamp doesn't sit there "twiddling its thumbs", it actually monitors your therapy and will switch from ramp mode to therapy mode, if it senses enough events to justify moving to therapy mode. Specifically:

• 5 consecutive snores
• 3 obstructive apneas or hypopneas within 2 minutes

Looking at the OP's sleepHQ data, there was a lot of snoring immediately before the pressure increase.

AutoRamp and it's switch to therapy criteria, is one of the most misunderstood features of Air10 and now Air11.I believe the OP would benefit from a higher ramp pressure. The abrupt increase from AutoRamp was not caused by the use of AutoRamp, the root cause was likely a pressure of 4. Switching to timed, would likely not have prevented all those events, instead hiding them.

[zonker]

Should I be concerned that 8cm as a minimum is considered good or bad? Or is the air pressure just something everyone has to experiment with until they find the balance?

as ozij said, the latter. as individuals, we don't all need one set of pressures. my minimum and maximum will be different to yours. same with ozij. or pretty much anyone else.

we experiment and rely on the software to guide us to what is best for individual needs. so we tweek and then see what works best. and this can take a bit of time to get what is exactly right for you.

patience is key in this therapy. it's why so many give up. so hang in there, you are in good hands.

good luck!

[decker12]

While I'm at work and not able to test this out, a couple more questions (off topic but it's better than making a new thread):

How often do you replace your tube, your mask/nose pillows, and the humidifier reservoir? My medical supply place seems to think I need new nose pillows every 2 weeks, a new mask frame and tubing every 3 months, and a new reservoir every 6 months. I haven't replaced anything but the little square filter on the Resmed device which I do on the 1st of the month (even though visually it looks fine). Their schedule seems excessive even though I'm pretty sure my insurance will cover it, it just seems wasteful. I do soap/water my tubing and nose pillows and frame every week.

Are you able to sleep without your machine? I know it's good for my body to use the machine, but I am still coping with the fact that this is my sleep life from now on. My nap attempts told me I can't even take a 30 minute nap without the machine because now I'm extremely aware of the.. "blockage" that I feel at the base of my throat when I start doing my sleep-time breathing. It literally feels like a rubber valve slowly descending and then plugging up which I then have to force myself to breathe heavier/differently in order to "unclog". Which basically means I can't ever get into automatic sleep breathing instead of active breathing. There will be times when I just can't the machine at all, like sleeping on a red-eye flight. And I'm also dreading the time when I have a mechanical problem with the device. As ridiculous as it sounds it's like I feel I should purposely not use the machine a day a week just to get my body accustomed to that possibility.

Thanks, you guys have been awesome. Is there a beer fund I can donate to?

[zonker]

While I'm at work and not able to test this out, a couple more questions (off topic but it's better than making a new thread):

no. please stay in this thread for the first few months of your therapy. consider this YOUR thread and everything in it is about YOU. that way, we can see what you have tried and will know what worked or didn't work for you.

How often do you replace your tube, your mask/nose pillows, and the humidifier reservoir?

unless you have a very specific need to have things clean (and i mean medically not just a "feeling"), you don't need to change things on their schedule. they are trying to make boat payments and need your help. i clean my stuff when it gets dirty, period. but then i am known on the forum to be both cheap and lazy, so there you go.

Are you able to sleep without your machine?

no i can't. and won't. i also can't read without my glasses. or drive for that matter. i had the power go out on me twice since cpap entered my life. could.not.sleep.without.it!

Thanks, you guys have been awesome. Is there a beer fund I can donate to?

nope. volunteers here who have been where you are and have an axe to grind against an industry that, for the most part, neglects (refuses?) to give people the info they need to make sleep apnea therapy WORK!

[ozij]

The auto ramp is a new feature, attempting to keep the machine "twiddling its thumbs" doing nothing as long as it thinks you're awake (up to 30 minutes, I think). In your case, it doesn't seem to be too good at discovering when you're awake and when you're asleep. Don't take it personally all those auto algorithms work for a majority of the population, but some of us fall through the cracks.

By the way, it's not psi, it's cm/H20.

AutoRamp is not a new feature, it's been around since the inception of the AirSense 10 and it does not *just* switch from ramp mode to therapy mode when it thinks you're asleep or when 30 minutes goes by.

Thanks for correcting me. I didn't realize (didn't know) auto ramp has been around since the A10.

AutoRamp and its switch to therapy criteria, is one of the most misunderstood features of Air10 and now Air11.I believe the OP would benefit from a higher ramp pressure. The abrupt increase from AutoRamp was not caused by the use of AutoRamp, the root cause was likely a pressure of 4. Switching to timed, would likely not have prevented all those events, instead hiding them.

Raising the ramp to 8 was actually my first suggestion. I suggested using timed for the test of how high a ramp is tolerable.
To summarize:
You think testing autoramp at higher start pressure will give the OP a good chance of finding out how that feels because there's a chance the machine won't sail into therapy mode. Therefore there's no inherent need to cancel the auto.
That makes sense.

[lynninnj]

SleepHQ is awesome! Just uploaded my data to it, and here's the public link for the past 90 days:

https://sleephq.com/public/96eb0ef8-117 ... 420b429e15

Thank you again for any insight you may teach me from that data!

Pressure settings aren’t just trial and error tho part of it is. Look at your pressure trends above and note the blue section. Touch/hover on any given day and note the “med” number. Most days are above 8. Once you try 8 for a while you readjust accordingly if necessary to optimize. But you want to give it a few days and get used to the pressure first.

one of the most important things is how rested you feel.

hth

[robysue1]

How often do you replace your tube, your mask/nose pillows, and the humidifier reservoir? My medical supply place seems to think I need new nose pillows every 2 weeks, a new mask frame and tubing every 3 months, and a new reservoir every 6 months. I haven't replaced anything but the little square filter on the Resmed device which I do on the 1st of the month (even though visually it looks fine). Their schedule seems excessive even though I'm pretty sure my insurance will cover it, it just seems wasteful. I do soap/water my tubing and nose pillows and frame every week.

Yeah, on the one hand the replacement schedule seems excessive. On the other, it's useful to have some backup supplies for when you do need them: Hoses don't often spring a leak, but if yours winds up leaking in the middle of the night, it's nice to be able to just swap it out for a different hose.

It's also kind of nice to swap out equipment that you want to wash with other stuff without the need to wait for the stuff you just washed to dry. Or even to swap stuff out without having to wash stuff every week. (I tend to drool a fair amount, particularly when my allergies are acting up, and I quite like being able to swap the pillows and their cozy out for new, dry ones after a bad night of drooling.)

So I'd suggest starting with using your insurance's replacement schedule, which may not be as generous as your DME expects. (For example, my insurance only wants to replace my nasal pillows once every 3 months, and the mask frame and tubing every 6 months, even though the manufacturer suggests more frequent replacements.)

Once you have a nice supply of "extras" stashed for when you need them, then you can start telling the DME that you don't need anything when they're nagging you about replacing your pillows or your mask frame or tubing if you're not ready to buy more supplies.

I'll also add that in my own experience, I need the disposable filters to be replaced much more frequently than is recommended. But then I'm pretty sloppy and my bedroom is often quite dusty.

Are you able to sleep without your machine? I know it's good for my body to use the machine, but I am still coping with the fact that this is my sleep life from now on. My nap attempts told me I can't even take a 30 minute nap without the machine because now I'm extremely aware of the.. "blockage" that I feel at the base of my throat when I start doing my sleep-time breathing.

It's difficult for me to sleep without the machine if I'm lying down. However, I can sleep sitting up in a car on long overnight ride without using the machine. Same thing with a redeye flight or an overnight bus.

But if I'm lying down? I'll usually be able to get to sleep, but it won't be a deep sleep and I'll usually wake up feeling worse than I did before falling asleep. It's a reminder (and not a pleasant one) of what my old normal was before I started CPAP.

I had an overnight train trip in Europe this summer. And hubby and I were in a crowed sleeper car (with 4 other people), there was only one electric outlet in the car and I was on a top berth with two people under me. (Hubby was immediately below me in the middle berth.) I tried to sleep without the BiPAP (which I had with me) because of the need to stretch the cord all the way up to my berth, and I woke up about 60 minutes into the night realizing that I hadn't really gotten much real sleep. So I wound up setting the BiPAP up in the dark, which included climbing down to plug the dang thing in, and pouring some bottled water into the humidifier tank since my nose objects to no humidification. I slept the rest of the night much more soundly, although I did wake up every time the train stopped for any length of time at station when there were power glitches that caused the machine to turn off. When we got to Utrecht in the morning, I was glad I'd found a way to use the BiPAP because we still had another train to catch to Amsterdam, followed some sightseeing and then a late afternoon flight to Iceland and another evening flight to Toronto.

It literally feels like a rubber valve slowly descending and then plugging up which I then have to force myself to breathe heavier/differently in order to "unclog". Which basically means I can't ever get into automatic sleep breathing instead of active breathing. There will be times when I just can't the machine at all, like sleeping on a red-eye flight.

Sleeping vertical in your seat on a redeye may be less problematic than when you are lying down. And some airlines may allow you to use a CPAP with a battery on-board. Overnight trains and overnight buses often have power outlets for every seat, and in that case you can use the CPAP on board.

And I'm also dreading the time when I have a mechanical problem with the device.

It may be worth while to invest in a battery pack for your CPAP for the occasional power outage.

But when something is wrong with the machine itself? You call the DME in the morning and if its a standard CPAP or APAP, they'll usually be able to get you set up with a loaner until your machine can be fixed or replaced.

This is also why a lot of us keep our old machine around when we finally are allowed to get a replacement machine by our insurance company. Or a lot of people will decide to buy a back up machine out-of-pocket. (If they're on a budget, some people are willing to buy a machine from Craigslist. Or if they are not comfortable with that, they'll see what secondwindcpap.com wants for a properly refurbished machine.)

[decker12]

I entered Clinic mode and set my Min Pressure to 8, and Ramp Up on Auto, with a starting pressure of 8. I did that both based on your suggestions, as well as looking at the graph and finding that my Median is always above an 8. So that makes sense to me! Looking forward to trying it out tonight!

Out of curiosity, how high does the pressure go? According to my 90 day graph my max was a 15, just once, but Max usually hovers in the upper 14's. I would guess if I was peaking out at 15 every night I would consider upping the Max?

Does Tube type have any effect on anything? Mine is set to Slimline, not sure what the difference between it and Standard is.

[lynninnj]

I entered Clinic mode and set my Min Pressure to 8, and Ramp Up on Auto, with a starting pressure of 8. I did that both based on your suggestions, as well as looking at the graph and finding that my Median is always above an 8. So that makes sense to me! Looking forward to trying it out tonight!

Out of curiosity, how high does the pressure go? According to my 90 day graph my max was a 15, just once, but Max usually hovers in the upper 14's. I would guess if I was peaking out at 15 every night I would consider upping the Max?

Does Tube type have any effect on anything? Mine is set to Slimline, not sure what the difference between it and Standard is.

Iirc slimline or climateline is the heated hose. There’s an unheated one -standard.

Hopefully we will hear you improved and have good news tomorrow.

You won’t be getting a ramp at all if your start pressure is 8 and minimum pressure is 8. Not sure how that works exactly.

[decker12]

If I'm not using the heated hose, should I turn off slimline and change it to Standard? Any idea what the difference is? I have the heated hose, I just haven't used it yet.

This is the first time I've been in the clinic menu so it's never been changed.

As far as the ramp up, you're right, if I'm at an 8 minimum pressure, and it's set to ramp up starting at 8, mine as well not be using it. According to my graph, I'm pretty much immediately ramped up to an 8 as soon as the machine detects I'm falling asleep. I'll keep it on anyway for a couple of nights and see.