Experimenting with a Resmed AirCurve 10

[robysue1]

Pugsy has kindly lent me a Resmed AirCurve to experiment with to find out whether I can make this machine work for me. And I've decided that I need a place to post my thoughts. And that's the purpose of this thread.

Rationale for the experiment
My PR DreamStation AutoBiPAP has been under recall for over a year with no information from PR about when it might (finally) be replaced. (I've continued to use it in spite of the recall because the benefit from getting a decent night's sleep outweighs the risk of continuing to use it in my opinion.) But the DreamStation is aslo 6 years old now. So it's due for a replacement under my insurance. mAnd I'll be under Medicare next year since I turn 65 next July. And my diagnostic sleep studies from 2010 and 2013 have Medicare AHI < 5 since all the hypopneas under on both NSPGs were scored using the AASM criteria that allows a hypopnea to be scored if there is an arousal even if there is not a corresponding 4% O2 desat. Hence, it's not at all clear if Medicare will pay for a replacement machine if I wait to buy one later. All of which raise the following questions:

Do I just continue to wait on PR to replace the current DreamStation AutoBiPAP? If so, are they just going to replace it with another (almost) 5 year old refurbished machine? (I can't see any evidence that a DreamStation 2 Auto BiPAP has been released.) Or do I just go ahead and upgrade to a new Resmed AirCurve 10 VAuto with my insurance now so that dealing with Medicare approval is not an issue?

The easy answer for most people would be to just go ahead and use my current insurance to pay for a Resmed AirCurve 10 VAuto and then accept whatever PR sends me as a back up machine.

But it's not quite that easy for me to make this decision for several reasons.

First, unlike most people, I had less than good results with a Resmed machine's EasyBreathe algorithm, albeit it was many years ago. In particular, when I was using a Resmed S9 AutoSet at the start of my xPAPing adventures, EasyBreathe and EPR never felt "easy" or "natural" to me: With EPR on, it felt like the AutoSet was encouraging me to inhale before I finished my exhalations. And it also felt like the machine was trying to encourage me to inhale longer than I wanted to inhale. And these sensations left me feeling as though the machine were trying to force me to inhale more and more and more air that I did not want to inhale and that I did not need to inhale. And that feeling of not being able to finish my exhalations happened on almost every breath while I was awake. And it caused me serious problems in getting to sleep. I also think it triggered air swallowing in me, which lead to pretty bad aerophagia. On the other hand, trying to get to sleep without EPR on was also difficult: I couldn't seem to exhale comfortably without EPR at all.

Second, I do seem to benefit from the PR BiPAP Auto algorithm's variable PS. On a PR BiPAP, the machine can independently increase IPAP without increasing EPAP. And even now my stomach greatly appreciates that on my DreamStation, the EPAP is seldom increased from its minimum setting of 4cm, even though the IPAP is regularly increased to 9cm, both from the PR "Search" algorithm and in response to flow limitations or hypopneas. And this in turn does a good job in letting me fall asleep (at 7/4) and stay asleep (at 8/4 and 9/4) while not triggering any serious aerophagia. And my AHIs are typically below 2.0, I wake up ready to get out of bed feeling rested, and I feel pretty decent in the daytime. The Resmed VAuto algorithm, however, has a fixed PS and it is based on EasyBreathe. So blindly jumping ship and buying a Resmed AirCurve seems a bit risky so to speak.

Third, if I do decide to use insurance to buy a Resmed AirCurve, I'll have a 50% copay. (Yes, you read that right.) And 50% of the cost of a Resmed AirCurve is a decent chunk of change. But if I wait until I'm on Medicare (when the copay should go way down), Medicare might just refuse to cover the machine completely because my OSA diagnosis is based on "hypopneas with arousal" and if you throw them out because they didn't have a corresponding 4% O2 desat, my RDI = 23 goes down to a Medicare approved AHI = 3.5. So in Medicare's eyes, I don't have OSA in the first place.

So I'm going to use this thread to post my impressions about the AirCurve as I'm experimenting with it in an effort to answer those questions about what I should be doing in terms of replacing the current DreamStation.

[robysue1]

Some lengthy background about my xPAP adventures (Skip if you're not interested)
I started CPAP on September 24, 2010 using a Resmed S9 Autoset in CPAP mode at 9cm with EPR =3. And while my AHI was great, I immediately started having severe problems with aerophagia, which in turn triggered some very severe insomnia. (If you want the long story, just search for the threads started by robysue back between September 24, 2010 and May 2011.)

Because of aerophagia issues, I was first switched from CPAP @9cm to APAP with a pressure range of 4-8cm. That helped a bit, but it did not eliminate the painful aerophagia I was experiencing on multiple days each week. And the insomnia continued to grow as I came to dread bedtime more and more out of fear of aerophagia. So back to the sleep lab for a bi-level titration. The titration study recommended bi-level with IPAP = 8 and EPAP = 6. Since there was going to be a several week wait for the machine, I switched the settings on my S9 back to fixed CPAP with Pressure = 8 and EPR = 2, since that gives an exhalation pressure of 6. This change did not do a damned thing for the aerophagia, which left me pretty anxious about the choice of what bi-level machine to choose.

Part of the delay in getting a bilevel machine was caused by the fact that the S9 VAuto was still "vaporware"---i.e. Resmed had announced that the S9 VAuto would be released, but no date had been announced. So my choices were either wait for an indefinite period of time before the S9 VAuto was released or buy a Resmed S8 VAuto (requiring a proprietary card and card reader to see the data in ReScan and no detailed flow rate data) or buy a PR System One BiPAP Auto (which uses an SD card, but at the time required Encore to see the data and even Encore Pro would not show the flow rate data by default). After a lot of reading and soliciting advice, I decided that the practical thing was to go with the PR System One (Series 50) BiBAP Auto.

I started the new year of 2011 with a brand new PR System One BiPAP Auto in fixed pressure mode with the pressure settings IPAP = 8; EPAP = 6. The first night, I turned Bi-Flex OFF and set Rise Time = 3 since Bi-Flex made it feel like the machine was rushing me to inhale before I was done exhaling. The switch to BiPAP (with Bi-Flex OFF and Rise Time = 3) took a real edge off the aerophagia---as in I was no longe waking up a lot with my stomach visibly distended and in pain several times a week. (There was a lot of speculation here at the time about why a System One BiPAP felt so much "better" to me than having the S9 Autoset running in CPAP with Pressure = 8 and EPR = 2. I won't rehash that debate here.) But even though I was no longer waking up multiple times a week with severe aerophagia, I was still waking up with milder aerophagia a lot. And it was clear from the sleep log I was keeping at the time that many of my middle-of-the-night wakes were associated with aerophagia---as in I had pressure in my stomach, even though it had not yet built up to the point of triggering significant pain. Back to the lab again for a second bi-level titration study, with the resulting recommended pressures being 7/4. That finally seemed to end the aerophagia, but in practice, the AHI started to creep up. So with the permission of the sleep PA treating me at the time, I changed to Auto BiPAP with Min EPAP = 4, Max IPAP = 8, Max PS = 4. The Series 50 BiPAPs had Min PS = 2 as a fixed setting that could not be changed in the clinical settings.

I also started 2011 with fighting The First War on Insomnia. The PA that I was working with was quite good at guiding me through the CBT-I that I needed to get over the severe insomnia that had set in during my first 3 months of PAPing. Sleep restriction was a critical part of the therapy (which is not for the faint of heart), but it did (eventually) help me teach my body to fall asleep within 10-15 minutes of putting the mask on my nose. And that in turn did a whole lot to get the aerophagia under control.

2012 was actually an OK year: The insomnia was more or less under control and the aerophagia was kept at bay and Auto BiPAP with Min EPAP = 4, Max IPAP = 8, Max PS = 4 kept my AHI under 2.5 most nights. And I was actually feeling good. But there was evidence that from an OSA/AHI point of view, increasing Max IPAP to 9 would have been useful. But every time I tried that, the aerophagia would come back---there would be times when the machine would increase EPAP up to 7, and those were the nights where the aerophagia was at it's worst. So I lived with 8/4 with Max PS = 4 as a working compromise: No aerophagia and an AHI < 3 on most nights was much better than some aerophagia and an AHI < 1.5 every night.

But something deteriorated in the spring of 2013: The migraines were spiraling out of control as was the insomnia. (The AHI was still good on most nights and aerophagia was only an intermittent problem.) The new sleep doc (Sleep Doc #4, who I really liked) decided that it would be useful to investigate the insomnia (and revist the OSA diagnosis) by doing another sleep test. It was originally supposed to be a split study, but the insomnia was pretty bad on the night where I was sleeping without a PAP machine (for the first time in over a year). The result still showed moderate OSA---with the vast majority of events scored as "hypopneas with arousal" that don't count for Medicare. The titration study also showed a lot of insomnia with a final bi-level pressure recommendations of IPAP = 6, EPAP = 4. A follow-up Actigraph study over a two week period confirmed that the severe insomnia on the two lab tests was not due to "lab effect": I wasn't sleeping any better at home (in terms of the insomnia) than I had in the lab. I didn't change the settings on my machine since I knew that 6/4 was not going to work in practice, and the sleep doc agreed.

So the Second War on Insomnia was begun. This time, in addition to going back to the CBT-I stuff, I also reluctantly started Ambien while waiting on Belsomra to finally make it to market. To cut to the chase: Ambien helped sometimes, but left me groggy; Belsomra was a godsend, however. And I kept taking the Belsomra for a long time. By the time the Covid pandemic started, I was using Belsomra on an "as needed" basis, but I was unable to get the scrip refilled after it ran out, and much to my pleasant surprise, I found that I could get to sleep night after night without it.

In 2016, my System One BiPAP turned 5 years old. And after some thinking about it, I decided to have insurance pay for a brand new PR DreamStation BiPAP Auto. With the ability to have a Min PS setting, I chose to set the DreamStation up with Min EPAP = 4, Max IPAP = 9, Min PS = 3, Max PS = 5. This resulted in marginal improvement in my AHI (fewer rare nights with an AH > 4) and substantial improvement in my sleep. How much of that improved sleep quality was due to the Besomra is a good question, however.

Which brings us to today: My DreamStation AutoBiPAP has been under recall for over a year with no information from PR about when it might (finally) be replaced. And it's 6 years old now. So it's due for a replacement under my insurance. And I'll be under Medicare next year since I turn 65 next July. And my diagnostic sleep studies from 2010 and 2013 have Medicare AHI < 5 since all the hypopneas under on both NSPGs were scored using the AASM criteria that allows a hypopnea to be scored if there is an arousal even if there is not a corresponding 4% O2 desat. All of which raise the questions I started this post with and all of which is behind the current experiment.

[robysue1]

First Impressions about the Resmed AirCurve 10 (non therapy things)

My first impressions are a mixed bag right now. Not negative enough to abandon the experiment, but not positive enough to make me contact my sleep doc and tell him, "Yeah, let's just replace the machine and not wait for PR to get around to doing it."

Things that I like (in no particular order)

• The machine is very small and very lightweight as compared to my DreamStation. The AirCurve's travel bag is also better designed than the DreamStation's bag. Traveling with the AirCurve would be easy, and I really wish I'd had this kind of a bag and this size machine when hubby and I were hauling my DreamStation and his System One Series 60 APAP around Europe for 45 days this summer.
• The LCD's information is so much more complete than the Dream Station's is. It's also much easier to get at. (I knew this would be the case---I never have liked the limited information available on the PR machines.)
• The patient menu allows the patient to set up the ramp time (but not beginning ramp pressure) and the humidifier setting. While the PR System One's have a knob to control the humidifier, the DreamStation's humidifier control is part of the clinical menu. Which makes it a pain in the butt to change the humidifier setting when there's a need to because of changing seasons. (I need less humidity when we're not using the AC on hot humid nights in the summer, for example.)
• Both the patient menu and the clinical menu seem easier to use. There is less twisting of the dial to get to things. The layout also is more intuitive.
• The machine came with a ClimateLine hose. , I have not yet used it because the last two nights have been (excessively) warm for Buffalo at this time of the year. We should have our first frost by next Saturday, so I may get the heated hose out by then.
• The humidifier tank. It seems to be easier to carry across the room when filled with water. Opening it is not as hard as I expected. I also like the fact that you don't have to open the machine up and take the humidifier tank out just to see how much water is left in the tank.

Things that I don't like (in no particular order)

• The way the hose is attached to the machine.[/i] I really miss the half-swivel on the DreamStation, and I always preferred the full swivel on the System One over the half-swivel on the Dream Station. In order to prevent a pretty significant bend/kink in the hose, I have to turn the AirCurve's front so that it is facing away from me and the hose is coming out directly at the bed. But even so, I pulled the machine around pretty significantly on the night stand.
• If you aren't using the ClimateLine hose, the hose connection is a bit finicky. Last night I inadvertently pulled my SlimLine off the AirCurve while I was trying to adjust the position of my hose. That has never happened on the PR machines I've used.
• The miniaturized on/off button. At least it's on the top of the machine. But in the last two nights, I've had some flailing around trying to find that button when I wanted to turn the machine off and then back on.
• The fact that the machine doesn't turn off when you press the off button. Yes, I know that the point of the reduced airflow is to dry the tube out. But in the middle of the night, I'm used to turning my machine OFF when I've woken up with air being blown into my eyes so that I can figure out what I need to fix (in terms of mask fit and/or where the exhaust flow is heading) without having air being blown around when I'm trying to do the middle-of-the-night troubleshooting. When I wake up in the middle of the night for no good reason, my stomach also appreciates turning the machine OFF and having a few breaths without any air blowing at me: With my DreamStation I just pull the pillows away from my nose, take a few deep cleansing breaths to relax, let the pillows settle back on the nose and then turn the machine ON and quickly get back to sleep. That doesn't work so well with the AirCurve since air continues to blow out of those pillows when I've pulled them away from my nose. So getting back to sleep after the random middle-of-the-night wakes was more difficult. The fact that the machine doesn't actually turn OFF immediately also irritated me when I looked at the data from the first night and realized it was all treated as "one session" because none of my turn the machine off/on wakes was more than 5 minutes long and so the blower never kept blowing. If there was a way to turn off this "feature", I'd do that in a heartbeat. Last night, when things were really bad I actually resorted to unplugging the machine just to get it to quit blowing air at me. That's not a long term solution to wanting a few minutes without air being blown at me. I also was worried that when I went to the bathroom (to escape the blowing air) that the blowing air might wake up my husband.

[robysue1]

First impressions concerning therapy and sleep quality
I've now slept two nights with the AirCurve.

I was expecting that it would take a bit of time and experimenting to get the settings correct and to also adjust to sleeping with the new machine. So I'm not surprised that the first two nights have had their problems.

So on to the report, so to speak:

Setting up the machine
Looking at the data for the last 3 months on my DreamStation, my median EPAP and my 95% EPAP are both 4cm. (This is also true for the past year.) There are the occasional nights where 95% EPAP = 4.5 and the exceptionally rare nights where 95% EPAP is above 5. (My theoretical Max EPAP is 6 on the Dreamstation.) Over the last 3 months on my DreamStation, my median IPAP is about 7.0 and my 95% IPAP is 9cm. (This is also true for the past year.) In looking at my data, the number one thing that causes the IPAP to increase from 7.0 is the PR "Search Algorithm". Flow limitations are the next most common cause for IPAP to go up, and then Hs. On a DreamStation, the only things that cause the EPAP to go up are OAs, snoring, and PS = Max PS when IPAP needs to be increased.

So figuring out a starting point for the therapeutic settings was the first thing to do. Given the Pressure settings on my DreamStation, choices for Mode, Min EPAP an Max IPAP were pretty straightfoward:

• Mode = VAuto
• Min EPAP = 4
• Max IPAP = 9

Since I'm used to PS being allowed to vary between 3 and 5cm on the DreamStation and since I know that my stomach does not do well when EPAP = 6 for extended periods of time, I settled on starting with PS = 4 because I don't want to be dealing with pressures of 9/6 for extended periods of time if I don't have to. With PS = 4, the AirCurve starts at 8/4, which is not quite as comfortable for me as 7/4, but (on the DreamStation), it's also not uncomfortable enough to keep me from getting to sleep in a timely fashion.

With the aid of both Pugsy and PaleRider, I settled on settings for Ti Min, Ti Max, Trigger, and Cycle. Taken together these are the settings that control how the EasyBreathe algorithm adjusts the pressure from EPAP to IPAP and back. There is nothing similar to any of these settings on a PR BiPAP Auto. (And that fact might explain why some people feel like the PR BiPAP just doesn't do a good job of "following" their breathing.)

I did a 10 minute wide awake session after setting the machine up in the middle of the afternoon. I was not lying down specifically because I wanted to focus on my breathing and the machine's response---both in terms of how it felt and in terms of what the pressure bar on the machine's LCD was saying.

Breathing felt marginally less comfortable on the AirCurve compared to the DreamStation, but not enough to be of significance. It felt far better than how I remembered EasyBreathe+EPR on the S9 feeling. In particular, I did not feel like the machine was pushing me to inhale before I was done with my exhalations. That was a truly awful feeling when I was using the S9 AutoSet back in 2010. (Awful enough for me to remember even after 12 years of PAPing.) On the other hand, I did still feel like there were times when the machine was trying to encourage me to keep inhaling more towards the end of my inhalations. In other words, as I wanted to decrease the rate that I was inhaling air, it felt like the machine was trying to push more air at me in order to encourage a deeper inhalation that I did not want to do.

I also know that my breathing patterns when I am trying to get to sleep can be ragged enough to make the DreamStation often scores an a FL or two, and sometimes an H or an OA, all of which can increase the pressure. On the DreamStation, except for the OA, none of these increases EPAP, and I typically don't notice increase in IPAP from 7 to 8.5 or 8 since it usually occurs over a two minute interval. But I know that Resmed machines respond pretty aggressively to even minor flow limitations, and so during my dry run, I held my breath for about 12 seconds. No surprise, once I started breathing again, the AirCurve immediately raised the IPAP to 9 and that drug EPAP up to 5. And my stomach was not so very happy with that. Moreover, it seemed like it took a long time before the machine to lower the pressure to 8.8.

So I made the decision to start with a Ramp period, hoping that the ramp was a SmartRamp that would start recording events and increasing pressure (if needed) after the machine thought I got to sleep. Since there's a few things going on in my personal life that are causing some stress, which in turn increases the time it takes me to get to sleep, I decided on a ramp of 30 minutes. But I'm going to need to rethink that decision. (More on that later.)

Night 1
On paper this should have been a good night's sleep, but it wasn't. Here's the data from Oscar:

Some things to keep in mind about this data, however.

1) Those long stretches where the pressure is at 8/4 are 30-minute ramp periods. And in zooming in, there are places where it looks to me like if the machine were set up to record stuff during the ramp, it would have scored some flow limitations and possibly a hypopnea or two or three. Some of the more obvious flow limitations occur during times when I think I was not fully asleep and so if there had been no ramp, the pressure would have increased up to 9/5 and stayed there.

2) Median EPAP = 5.0 and Median IPAP = 8.7 and my stomach was feeling that the next morning. I had more aerophagia in the morning than I've had in a while and it's reasonable to think that the increased pressures might be responsible: Recall that my 95% EPAP on the DreamStation has been running at 4cm on almost every night for a long time with little or no aerophagia and my median IPAP has been running around 7 to 7.5 for a long time.

3) There's enough Flow Limitations being scored by the AirCurve that its clear the AirCurve would have loved to have increased the pressures even further if Max IPAP were set higher than 9. Which in turn may have pushed the uncomfortable aerophagia into becoming "painful aerophagia."

4) That bit of snoring between 8:30 and 8:45? On the DreamStation that would have pushed my EPAP up to 5 or even 6. But the rest of the night? My EPAP would have stayed right at 4. So the 95% EPAP might still have been 4cm even with a 15 minute period where EPAP = 5 or 6.

5) Three middle-of-the-night wakes are not unusual for me. Most of the time with the DreamStation, I hit the off/on button, turn over, and go right back to sleep. (I'm often amazed that there are multiple sessions in my data because I literally don't remember most of those wakes.) Subjectively at least one of the wakes on this night seemed like a "long" one and I do remember being uncomfortable in terms of tummy pain (aerophagia) during that "long" wake.

6) The change in breathing pattern that starts a little after 5:00 AM is interesting. Clearly I'm restless for the next hour or so, but I don't think I was awake the whole time. Here's a close up of the beginning of that restless period that shows the first two hypopneas, which to me look like they might be post arousal events:


7) Subjectively it took me a lot longer to fall asleep on this night than usual. Whether it was just the change of machine or whether it was stuff going on in my private life that is stressing me out is a good question. Objectively, however, the CPAP data and my FitBit both show that I was very likely asleep within about 5-10 minutes of turning the machine on.

8) My nose was on the dry side when I woke up, but not painfully dry. And I had turned the humidifier all the way up to 8 even though I know that maximizes the chances for rainout. I did not, however, have any problems with rainout. Perhaps it's because the night was warm and humid. Perhaps it's because I have a hose cozy on the hose and run the hose under the covers and next to my body. On the DreamStation, I use "Classic 5" for the humidifier setting. "Classic" means the machine does not try to compensate for the ambient relative humidity or temperature and 5 is the max setting. Classic 5 is almost guaranteed to create rainout problems, and I do regularly wake up to gurgling noises when using the DreamStation, but I just raise the hose and the water runs back to the machine's humidifier tank. And while I'm in a minority, I do tend to prefer a literally wet nostrils (from condensation in the nasal pillows mask) to waking up to a dried out nose. Oddly I never had any rainout problems with the S9 Autoset back in 2010 and I had the humidifier cranked up to 8 on that machine as well.

Overall, Night 1 was a mixed bag. It was not an overwhelming success, but it was also not an abject failure. Waking up with aerophagia in the morning is a concern. And I also need to rethink the ramp time.

I'll write more about Night 2 after I look at its data later today or this evening.

[palerider]

[*]The fact that the machine doesn't turn off when you press the off button. Yes, I know that the point of the reduced airflow is to dry the tube out. But in the middle of the night, I'm used to turning my machine OFF when I've woken up with air being blown into my eyes so that I can figure out what I need to fix (in terms of mask fit and/or where the exhaust flow is heading) without having air being blown around when I'm trying to do the middle-of-the-night troubleshooting. When I wake up in the middle of the night for no good reason, my stomach also appreciates turning the machine OFF and having a few breaths without any air blowing at me: ... The fact that the machine doesn't actually turn OFF immediately also irritated me when I looked at the data from the first night and realized it was all treated as "one session" because none of my turn the machine off/on wakes was more than 5 minutes long and so the blower never kept blowing. If there was a way to turn off this "feature", I'd do that in a heartbeat. Last night, when things were really bad I actually resorted to unplugging the machine just to get it to quit blowing air at me. That's not a long term solution to wanting a few minutes without air being blown at me. I also was worried that when I went to the bathroom (to escape the blowing air) that the blowing air might wake up my husband. [/list]

The machine *IS* OFF during cooldown as far as recording user data and user sessions is concerned.

Are you using sleephead to look at the data? There's a 'feature' in sleepyhead to ignore short sessions and combine sessions that have short breaks.

[robysue1]

The machine *IS* OFF during cooldown as far as recording user data and user sessions is concerned.

I know that is true for user data.

But the dang air is still blowing in my face when its 3:30 am and I just want to turn the air blowing in my face off for a couple of minutes while I fiddle with the mask or hose or bed covers or my alarm clock or the iPod that plays the chant music while I awake and take a few deep, relaxing breaths when I have the pillows pulled away from my nose before I turn the machine back on and snuggle back down to go back to sleep.

But the dang air keeps blowing in my eyes and at my face. Yes, it's not the hurricane that blows full therapeutic pressure, but it's still noticeable in the middle of the night and it's deeply disturbing that the machine is still hissing at me even though I have hit the off button at 3:30 AM. And last night (Night 2) the fact that the air was still blowing around while I was fiddling with my headgear caused me to become much more awake and it made it much harder to get back to sleep.

Are you using sleephead to look at the data? There's a 'feature' in sleepyhead to ignore short sessions and combine sessions that have short breaks.

I mainly use OSCAR these days. And I never used the "feature" to combine sessions with short breaks in between them even though I was aware it existed. And I have not changed my OSCAR/SleepyHead settings concerning short sessions.

Here's the OSCAR view of the last night I used the DreamStation with the left sidebar scrolled to show all the session times:

You can see there's one 3 minute session (at the beginning of the night) that I turned off because I wasn't settled and the data was unimportant. You can also clearly see that the night's main sessions are all long enough to conclude that I most likely got one full sleep cycle between each session. Hence the wakes between the sessions (which I did not remember the next morning) are all likely pretty normal post-REM wakes.


Here's the OSCAR view for first night with the AirCurve:

The 8 minute session that is turned off is the "dry-run" when I was testing the Trigger, Cycle, Ti Min, and Ti Max settings in the afternoon.

That 7:14 session? It's not one session in terms of night time "turn the machine off and then turn the machine back on" cycles. Every break in the pressure curve is caused by me turning the machine off and then back on. There are 4 such breaks: A wake at roughly 3:30, a second wake at roughly 6:45, a third one (that is hard to see unless you zoom in on the data) at 7:06, and a forth wake at roughly 9:00. I never did get back to sleep after that 9:00 wake, but there's no way to turn that final session off because it's bundled in with the other sessions.

Note too, each of these wakes is no more than a couple of minutes long, and hence the time the machine was in cool-down mode, when I turned it back on. And as near as I can tell, that's why OSCAR is reporting all of these separate sessions as being part of one super long session that started when I turned the machine on at the beginning of the night and turned it off for a period that was long enough for it to complete its full cool down cycle.

[robysue1]

The machine *IS* OFF during cooldown as far as recording user data and user sessions is concerned.

Are you using sleephead to look at the data? There's a 'feature' in sleepyhead to ignore short sessions and combine sessions that have short breaks.

The plot grows thicker.

When I look at the data from my DreamStation in OSCAR, all of the sessions show up as individual sessions:



When I look at the data from the AirCurve in OSCAR, all of the sessions are combined into one mega-session:



When I look at the data from the AirCurve in SleepyHead, all of the sessions show up as individual sessions:


Please note: My copy of SleepyHead and my copy of OSCAR are using very different time offsets. Oscar corrects for the current clock drift in my PR DreamStation. SleepyHead corrects for the clock drift in my old PR System One.

I've looked in Oscar's preferences and I sure can't find anything setting that would "combine" sessions. And Oscar shows the individual sessions for my S9, my System One, and my DreamStation correctly.

[robysue1]

Impressions from Night 2
I went to bed around 1:40 EDT, which is an early-ish normal bedtime for me these days. I had a bit of trouble getting to sleep: I was being distracted by "Darth Vader" sounds (which I don't seem to have with the Dream Station) and the big rainstorm we were having was also distracting me. But according to my fitbit I most likely fell asleep by about 2:07 EDT and the flow rate data settled into a decent sleep breathing pattern shortly after I turned the machine off and back on at 2:05 EDT because I was trying to fix a leak, which was hard since the AirCurve keeps blowing air after its turned off because of the "cool-down cycle" designed to dry the hose.

Overall Night 2 was a lot rougher than Night 1 was. It was rougher in terms of number of wakes. It was rougher in terms of aerophagia. And it ended with me getting quite angry at the AirCurve 10 by the premature end of the night. (In terms of AHI, it was about the same: The Oscar reported an AHI = 0.97 for Night 1 and 0.85 for Night 2.)

How premature was the end of the night? Well, I woke up around 6:30 EDT incredibly uncomfortable with aerophagia---my usual wake up time (without an alarm) has been around 9:00 AM EDT since we returned from our trip to Europe this summer. When I woke up around 6:30, there was a modest size leak blowing in my eyes at the time---the data says the unintended leak rate was just under 10 L/min. And the jet stream exhaust flow from the Swift FX was also disturbing me, so I tried turning the machine off, but the dang air kept blowing at my eye because of the "dry the hose" cycle/"cool down" cycle that is built into the AirCurve's programming. I also wanted to adjust the backstrap of the headgear but the air from the "cool down" cycle was highly distracting and I was having a real problem getting the nasal pillows to sit right on my (somewhat) dry nostrils.

After a couple of minutes, I thought I had things fixed, so I turned the machine back on, but nope, the pillows were still leaking imperceptibly. I spent about 8 minutes trying to fix the leak and/or protect my right eye from the air that was blowing into it before turned the machine off again.

But this time I was so frustrated with the fact that the air kept blowing at my eye even after turning the machine off that I decided to just unplug the damn thing. That, of course did end the airflow from the "cool-down" cycle. While the machine was unplugged, I fiddled with the pillows and headgear for about 8 minutes and thought I'd gotten them "fixed." So I plugged the machine back in and turned it back on abut 8 minutes after I turned it "off" and then unplugged it.

I tried to settle back down, but a pesky low level leak was still present. By pesky low level leak, I mean the unintended leak was all of 3 L/min or so. But it was somehow hitting my eyes. And at this point my stomach was definitely complaining about feeling bloated---as in it was rigid with air. I just couldn't get comfortable so I finally turned the AirCurve "back off" about 8 minutes after I had plugged it in and turned it back on." This time I immediately unplug the machine as soon as I turn it off: The airflow from the "cool-down cycle" is just making me irritated, more awake, and mad.

Because the stomach is hurting and because I know that I've got the ramp set to 30 minutes, but the machine doesn't record events during the ramp period, I decided that I would plug the machine back in and reset the Max Pressure setting to 8cm so that I could turn the ramp off and still know that EPAP won't go up to 5cm just because of SWJ events.

Plugging the machine in and resetting the Max Pressure to 8cm only took a couple of minutes. So I turned the machine back on at 7:02 according to Oscar. While I was trying to get back to sleep, the Darth Vader breathing noises, which I usually do not have, started up and they were really pronounced and also irritating because I was uncomfortable due to the aerophagia.

After fighting to get back to sleep for about 20 minutes (and dozing for maybe 5 of those minutes), I got fed up enough to turn the machine off again. By this time I was simply fed up with the whole thing. I tried one more time to turn the machine back on, but I turned it off just two minutes later and decided to get up with my husband, who I had woken up with all of the restlessness that started around 6:30 EDT, or 5:30 EST.

So yeah, Night 2 was not a good night.

In retrospect, I suspect my mask's pillows may be a major culprit: Even before starting the current experiment with the AirCurve, I had been waking up more than usual with pesky leaks blowing in my right eye. So I think this pair of pillows may be shot. I also know that in the last week or so, the Swift FX's exhaust has been bothering me more than usual for this fall.

So rather than play with the settings (yet), tonight's experiment consists of swapping out the pillows for a different set, securing the silicone top strap to the Pad-a-cheek pad that goes under that top strap with a safety pin, and putting my homemade exhaust diffuser back on the exhaust vents. It's been a long, long time since I needed it, but since the Darth Vader noises and the pesky leak that blows into my right eye were so bothersome last night, I decided it's time to make a new diffuser and see if that makes any difference in terms of comfort level.

With the help of my applied math hubby, I've also decided that I'll be tracking two fundamental, but subjective variables, for my overall sleep quality while continuing this experiment: With each set of settings that I try out on the AirCurve, I'll keep track of whether aerophagia is an issue and whether there seem to be enough (irritating) wakes/arousals to negatively affect my sleep. That way I can test the hypothesis about whether I'll sleep worse (or better) with the AirCurve than I do with the DreamStation.

Ultimately, the goal is to tease out from the aerophagia and arousal data whether I can just go ahead and start working on figuring out if its a good idea to just replace my 6 year old DreamStation with an AirCurve if our insurance will pay for a replacement machine.

I'll keep using this thread to update things so that I have my written (qualitative) thoughts all in one place when it's time to make a decision.

And now I really do need to go to sleep since I'm starting to yawn.

[robysue1]

Night 3
If Night 2 was a near disaster, Night 3 was a pretty solid success.

I kept the settings the same (Min EPAP = 4, Mas IPAP = 9, PS = 4), but in reflecting about Night 2's problems, I realized that I'd been fighting pesky leaks all week long with the set of pillows I was using. And I had not really gotten the top strap on the Swift FX headgear properly adjusted since I'd swapped stuff out several days before starting the experiment with the AirCurve.

So I went back to basics: The mask has to seal well and the headgear has to not get too tangled in my hair. Since the pillows had been creating pesky leaks for some time, I decided I'd swap them out, and get rid of the pillows that were just not sealing. I have no idea just how old these pillows are, but they're not new. What often happens when the pillows are not well worn is that the inner cones can collapse or partially collapse. And when that happens I get these pesky little leaks that seem to take forever to fix and then they just don't stay fixed.

I also realized that I needed to use a safety pin to attach the top of my Swift FX headgear to the top of the very old Padacheek frame pad. I believe that the pad I'm using is the very first one she made---I contacted her about custom making me a pad for the Swift FX way back when in 2010 or 2011 when she had no such pad on her website. This very old pad has a different design than the one she currently has on her web site. And because I have a small head, my headgear's top strap setting makes it slip off the pad and then both get tangled in my hair---unless I use a safety pin to anchor the frame to the pad.

I also turned the "ramp" off. Essentially all the ramp was doing was delaying the AirCurve's ability to start increasing the pressure in response to events, flow limitations, and snoring. I figured I had the ramp time set way too long on Night 2, and that if switching out the pillows and refitting the headgear did the trick of fixing the pesky leaks I probably wouldn't need the ramp---in other words, I'd probably be asleep or close to it before flow limitations caused an increase in pressure.

I also realized that the Darth Vader breathing noises coming from the hose were more-or-less magnifications of the noise generated by the exhaust vents when the pressure changed between EPAP and IPAP. This does not seem to bother me as much (anymore) when I'm using the DreamStation, but for several years I used a homemade diffuser to keep the jet flow from the exhaust vents from blowing on my arms and chest. So I got the foam block that I cut these diffusers out of my CPAP supplies drawer and made myself a brand new one.

Well, between the different set of pillows, the safety pin securing the top of the headgear to the Padacheek pad, and the diffuser, when I put the mask on and turned the AirCurve on, there were no leaks, no headgear slipping all over the place aggravating the leaks, and no Darth Vader noises. It felt wonderful. And I got to sleep almost immediately---as in no more than 5 minutes. The Fitbit data and the flow rate data both seem to agree with that impression.

According to OSCAR, I turned the machine off and back on 3 times during the night. But the time between the wakes were between 90 and 105 minutes and two of them were so short I don't remember them. The one wake I do remember, I did need to fix a small leak, but that was easy. However my husband also woke up around the same time to go to the bathroom. And I didn't get back to sleep until he came back to bed.

At the wake I remember I was still frustrated that turning the AirCurve off does not turn the blower off, but rather triggers the cool down cycle. However, because I didn't have any difficulty with fixing the leak, the blower being on didn't bug me as much as it did on night 2.

Aerophagia was much less of a problem on Night 3. Yes, there was a tiny bit of bloating, but no where near as much as on Nights 1 and 2. In other words, the bloating was no worse than what I sometimes have with the DreamStation.

I'm also just a bit worried about the humidifier setting. I've got it set to 8 and I'm still using an unheated SlimLine hose. And my nose is dry and it's stayed dry all day. Given the near perfect leak line, I can't blame the dryness on leaks. So I think I'll use a neti pot before heading to bed tonight. I haven't gotten any rainout in either the hose or the mask (yet), but I can't turn the humidifier up past 8. My nose has been happy with the humidifier set to "Classic 5" on the DreamStation. Classic 5 is the maximum non-smart humidifier setting on the DreamStation---it makes no adjustments for the ambient relative humidity. And I do have pretty regular rainout problems in the hose when I use the DreamStation, particularly if the hose sags down and creates a low spot before where it comes under the covers with me. And yes, my nostrils sometimes feel wet from condensation in the pillows. So it appears that my nose is missing the ability to have the air in the tube being pretty close to super-saturated. Even on 8, the Resmed humidifier is "smart" in the sense that it takes the ambient room temp and relative humidity into account in order to try to prevent rainout.

I woke up around 8:15 Standard time (9:15 Daylight time) without an alarm, and I was able to out of bed without any problems at all: I felt rested and ready to get up. I always try to use the fall time change to "get up earlier" since "getting up earlier" is accomplished by simply getting up at the same time I've been getting up. But if I struggle with sleep during the first week after the time change, that plan can go bad pretty quickly.

I plan to keep using the current settings on the AirCurve several more days before making any changes. (There is one change that I am thinking about doing in a week or so just out of some curiosity.)

And I'm going to keep a "basic score card" so to speak with the current settings based on three fundamental variables I tend to use for determining how well I'm sleeping: Aerophagia, wakes, and feeling on waking.

Here is the current score card right now:

Aerophagia: 2 nights worse than usual compared to the DreamStation; 1 night about the same as the DreamStation
Wakes & Arousals: 2 nights worse than usual compared to the DreamStation; 1 night about the same as the DreamStation
Feeling on Wake: 1 night worse than usual compared to the DreamStation; 2 nights about the same as the DreamStation

[ozij]

Sounds encouraging!

According to OSCAR, I turned the machine off and back on 3 times during the night. But the time between the wakes were between 90 and 105 minutes and two of them were so short I don't remember them. The one wake I do remember, I did need to fix a small leak, but that was easy. However my husband also woke up around the same time to go to the bathroom. And I didn't get back to sleep until he came back to bed.

That must be 90 and 105 seconds, can't be "minutes"....

[robysue1]

Sounds encouraging!

According to OSCAR, I turned the machine off and back on 3 times during the night. But the time between the wakes were between 90 and 105 minutes and two of them were so short I don't remember them. The one wake I do remember, I did need to fix a small leak, but that was easy. However my husband also woke up around the same time to go to the bathroom. And I didn't get back to sleep until he came back to bed.

That must be 90 and 105 seconds, can't be "minutes"....

Nope. The wakes were about 90-105 minutes apart:

Wake #1 occurred about 3:05 AM
Wake #2 occurred about 4:50 AM
Wake #3 occurred about 6:30 AM

Wake #1 lasted about 3-5 minutes
Wake #2 lasted about 3-5 minutes
Wake #3 lasted about 15 minutes. This is the one where I had to fix the leak and hubby went to the bathroom.

[ozij]

Got it. I misread "the time between the wakes".

[robysue1]

Night 4
Night 4 was a qualified success.

In terms of therapy, it was a smashing success: An AHI = 0.0. (I don't see those very often on the DreamStation.) And that AHI 0.0 is not caused by too short of a time period. Here's the screen shot of the data in SleepyHead (Oscar doesn't show the sessions correctly):


In terms of aerophagia, this was a decided improvement. Of course, this is also the first night with the AirCurve where Median EPAP was at 4.0. (On the DreamStation, my Median EPAP was always 4.)

The nose is happier this morning as well. The humidifier did use more water last night that on previous nights, most likely because the ambient relative humidity has gone down quite a bit. I did get a bit of rainout in the hose for the first time, but less than I often get on the DreamStation. The rainout accumulated right where it always does---a low spot caused by the hose sagging between the machine and where it gets routed under the bedcovers. It was easy to fix the problem by just lifting the low spot in the hose up and letting the accumulated water flow back towards the machine.

A small amount of rainout is something that I've learned to tolerate: My nose is happiest when I get rainout, even if the ears, my brain, and my hubby are not always pleased to wake up to the sound of a gurgling hose. I swear that my nose wants the air coming into the mask to be at as close to 100% relative humidity as possible. (My nose also likes hot, steamy showers and dense foggy weather.) So as long as the rainout is minimal and lifting the hose fixes the problem once (or at most twice) a night, I'll live with it. The alternative is a painfully dry nose when I wake up.

And I'm also feeling reasonably well rested, given that this was a night where I went to be late (2:45 AM) and got up early (7:52 AM). But I can't blame the short sleep window on the AirCurve: I just didn't get sleepy enough to go to bed until it was 2:45, but I did wake up ready to get out of bed around 8:00. (And I'm currently trying to stabilize that wake up time with the use of a lightbox in the morning now that the time has changed.)

I also did figure out how to turn the machine off in a way that actually turns the blower completely off rather than leaving it blowing in the cool down cycle. While re-reading the entire Clinical Menu, I ran across instructions on how to put the AirCurve into Power saver mode by holding the on/off button down for 3 seconds. On one or more of the wakes in the middle of the night, I did that and low and behold, the blower did turn off. So I was able to do what I wanted (probably a minor mask adjustment) without the distraction of air being blown at me. The downside is that you have to press the on/off button twice to start therapy. That's not a huge drawback in my opinion.

So why is last night's success a "qualified" success?

1) I pulled the hose off at the beginning of the night when I was trying to eliminate the "low" saggy spot to minimize the chances of rainout accumulating there. And I had to turn the light on to fiddle with getting the hose back on because reattaching the hose is not as easy as it is with the DreamStation. I really don't like the way the hose attaches to this machine. It's not at all friendly to attaching an unheated hose. Maybe it's better with a ClimateLine hose. And I do plan on experimenting with the ClimateLine after my initial set of experiments with my current equipment runs a week or so. But between hubby and myself we've got about 8 or 9 unheated hoses and it seems silly to not use them.

2) Once the hose was pulled off, the machine immediately went into some kind of a panic mode with a warning of a "Large Leak" message about the dang hose. The problem here was that I could not figure out how to get the machine to make the panic warning go away after I reattached the hose. As a consequence of the machine's panic, it would not allow me to turn the machine back on after I reattached the hose because I had not properly "cleared" the alert or some such thing. (The machine's LCD faces away from me so that there's not a sharp bend in the hose and I need my glasses to read the screen anyway.) After a few minutes of frustration, I simply yanked the cord out of the machine. When I plugged it back in the machine was happy enough to allow me to turn it on and allow me to get back to sleep. Overall, however, I think there's a pair of design flaws here: The hose should not be that easy to yank off the machine. And when it is yanked off, the machine ought to let you turn it on after reattaching the hose without making you go through some kind of menu jumping to turn the alert off.

3) There was more restlessness than usual during the night. I remember being restless during part of the night and turning the machine off and back on a couple of times without getting much sleep between the two times I turned the machine off and back on. Since I don't clock watch, I don't have a subjective idea of what time this restlessness started or when those two times I turned the machine off and back on actually happened. In looking at the data, it's pretty clear that the restlessness happened between 5:50 and 6:30. Not only are there two obvious wakes in the SleepyHead/Oscar data, the FitBit also shows 5 wakes during that same time period mixed with some Light Sleep.

Here is the score card through Night 4:
Aerophagia: 2 nights worse than usual compared to the DreamStation; 2 night about the same (or better) as the DreamStation
Wakes & Arousals: 3 nights worse than usual compared to the DreamStation; 1 night about the same (or better) as the DreamStation
Feeling on Wake: 1 night worse than usual compared to the DreamStation; 3 nights about the same (or better) as the DreamStation

[palerider]

2) Once the hose was pulled off, the machine immediately went into some kind of a panic mode with a warning of a "Large Leak" message about the dang hose.

Might want to turn off the Leak Alert, (if it's on) and turn on SmartStart, it works worlds better than what Respironics attempts to do.

[robysue1]

2) Once the hose was pulled off, the machine immediately went into some kind of a panic mode with a warning of a "Large Leak" message about the dang hose.

Might want to turn off the Leak Alert, (if it's on) and turn on SmartStart, it works worlds better than what Respironics attempts to do.

Leak Alert is OFF. So at least the machine wasn't beeping or howling at me with an acoustic alert. The flashing LCD was bad enough. I can't imagine dealing with an acoustic alert as well.

Since I use nasal pillows with a starting EPAP = 4 and starting IPAP = 8, SmartStart is not recommended. Besides, I hate SmartStart. Turning the machine off and back on with the on/off button is what I prefer. In part because when I wake up and want to turn the machine off and back on, I don't always want to take my mask off and then wait for the machine to decide I'm no longer wearing the mask.