A-Flex - First Night

[Goofproof]

8 CM TO 12 CM No ramp. You need the software ASAP, the readout is confusing and not to be trusted, it measures avgs. To use it you have to zero the data daily, and yes the prople who set the machine are fools, but then again they weren't going to use it, so why would they bother learning how to set it up. Jim

[Snoredog]

I'm not a doctor or anything in the health care field.

I'd set the machine at 8 for the minimum pressure, 16 for the maximum pressure. Try different A-flex settings to see which feels most like natural breathing to you.

I'd keep ramp turned off unless you absolutely need a ramp time with a lower pressure to start out. But I'll bet that using A-flex will make ramp unnecessary for you.

IF the ONLY thing you are trying to fix is a high AHI, then I'd say yes increase the Auto:Min pressure to 8 and I'd also open up the Auto:Max.

I suspect the residual AHI=25 is most likely from his self-imposed Auto:Max=10 as opposed to using a low Auto:Min=4.0 Remstar Auto doesn't usually let it run up that high if allowed to correct it.

BUT his goals are two-fold:

1. Eliminate the adverse side effects from Aerophagia.
2. Obtain a low AHI and hopefully restorative sleep.

But the fact remains if you jack up the Auto:Min pressure to where he was on CPAP only to achieve a low AHI, you have NOT addressed his goals with Aerophagia.

Using an autopap to find your ideal pressure is not the only use of the machine.

Sometimes you have to let that AHI climb up a bit to dance around other known symptoms he is also trying to address.

Elimination of the aerophagia pains can take a week or more to see any improvement. If you start at a pressure that doesn't eliminate it, you have no idea if a lower pressure would help or be better. I always try to use the minimum pressure needed to do the job.

I agree 4.0 cm was too low, reason I suggested the 6.0 or 6.5, but I also have the same problems with aerophagia and it will return using my 420e at 6.5 pressure reason I go back and forth between it an AFlex.

I also agree an AHI=25 is way too high, you are only 5 points from being Severe. Many come here with one foot in the grave with lower AHI's. I suspect that score was caused by the 10.0 cm imposed limit vs the Auto:Min being too low.

But maybe he will be lucky and the aerophagia symptoms will go away with it at 8.0 on Aflex.

[roster]

After the second night with A-Flex, I feel bad this morning. The statistics are in line with my feelings.

The system ran with the following settings last night: min pressure 7 (increased from 4), max pressure 12 (increased from 10), A-Flex 2 (no change).

I took the averages from the machine for 2 days and calculated the actual statistics for one day (Second day actual = 2 times average minus first day).

Statistics for one day

- Usage 7 hrs 42 minutes

- 90% pressure = 12

- Leak 7 days calculates to 14.2 (this must be machine error)

- Leak 30 days calculates to 36.8 (this seems correct and should be normal for this mask and pressure)

- Therapy hours 7.5, Blower hours 7.9. This doesn’t make sense because I did not leave that machine on for 24 minutes with the mask off.

- AHI 31.7 – This correlates with how crummy I am feeling this morning.

I had fairly bad aerophagia this morning. Just like on cpap, it only happens when I roll to either side. I can hear air gurgle down my esophagus when I roll to either side and the stomach fills with air within a few minutes. I have had dry mouth both nights but not as bad as with straight cpap.

So since the max pressure setting was 12 and the 90% pressure was 12, then I am thinking tonight maybe to set it to min 10, max 14 and turn the A-Flex feature off until I can figure out what pressure settings are needed. Eh?

My almost 2 year old sleep study and titration yielded a prescription for 10 cm straight cpap. The doc said 7 cm took care of most apneas/hypopneas but the lab pushed it to 10 cm to take care of the snoring. This certainly does not correlate with the data I am seeing on the A-Flex screen. I have not gained weight since the sleep study and in fact have lost just a few pounds. I am six feet/165 lbs.

As the machine cycled up and down last night, the sound of the air rushing through the hose and mask was very loud. It did not seem to bother me much maybe because I am tired enough to sleep through most things.

BTW, compliance check was 14033 first night and 40143 second night. What the heck does that mean?

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CPAPopedia Keywords Contained In This Post (Click For Definition): hose, Titration, CPAP, AHI, Prescription, aerophagia

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CPAPopedia Keywords Contained In This Post (Click For Definition): hose, Titration, CPAP, AHI, Prescription, aerophagia

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CPAPopedia Keywords Contained In This Post (Click For Definition): hose, Titration, CPAP, AHI, Prescription, aerophagia

[Snoredog]

I think you are missing something important from your PSG/titration report.

I don't think the data you are looking at on the LCD is very accurate, you need to clear the Therapy menu, sounds like it may have some factory bench-test data included those machine results. Clear the Therapy data and it should give you more accurate results the next day.

==========Resetting LCD Display Data====================

To reset LCD Therapy data (does NOT erase any data from SmartCard):

1. Hold down the (<-) (->) buttons while plugging in the power on the back,
wait for 2 beeps or 5 seconds, release buttons.
2. Press the (->) key and navigate to Therapy screen.
3. Press and HOLD down the (-) minus key for 5 seconds and/or until therapy data is reset to Zero.
4. Press the (->) key to scroll back to main menu, press (+) key to enter Setup or
On/Off button to exit.

If your PSG shows any CA or MA events denoted, then you may need to keep your pressure under 9.0 cm. Does that PSG data include a titration table where your doctor indicated most events taken care of at 7 cm pressure?

They put you on CPAP@10 cm and you have been fighting it ever since. Sometimes they bump you up blindly from that 7 cm which can be enough to trigger a series of CA's. Then when you go on a autopap to find a pressure those same CA's fake out the machine and drive up the pressure right away to any set Max pressure. IF that is the case, then you set the Auto:Max=9.0 cm and set the Auto:Min=6.5, range becomes 6.5 to 9.0.

You may also throw a dart and set the machine to a straight 8.0 cm pressure in CPAP mode and compare that new AHI to what you have been getting that would tell you if the changing pressure from the autopap is the cause of the higher AHI.

Also if for example; you have sleep onset events that are the cause of the wigging out the machine, use of a 30-minute Ramp even if that Ramp pressure is same as Auto:Min pressure the machine will ignore the first 30 minutes of sleep, then when those subside machine will begin normal therapy and the onset events that wigged out the machine will be gone. This usually results in a lower AHI score and/or can get you over that hump. If it seems like you fight it to fall asleep that may be and indicator of the sleep onset events or it may resemble forgetting to breathe.

Note: there are many options you can try with that machine. AFlex only works in the Auto mode. The "Flex" setting can only be disabled or turned off in the Setup mode. If you flip the mode from AFlex to CFlex then the Flex setting controls that, if you want it in CPAP mode you set mode=CFlex then set Flex=Off. Flex can be changed from the User menu (from 1 to 3) but only disabled via Setup, same for AFlex settings. If you select AFlex mode then turn Flex=Off, you are then in the Autopap mode without any exhale relief.

I've tried disabling the Flex features and my aerophagia only got worse (even only going from #2 to #1 setting).

[roster]

Does that PSG data include a titration table where your doctor indicated most events taken care of at 7 cm pressure?

I only have a summary but the sleep doc told me 7 cm took care of most of the events.

The same doc lowered my pressure to 7 recently. Later his technician frowned at this and told me she thought eventually I needed to get back to 10 (go figure).

I ran the straight cpap at 7 for two weeks, wife said I snored and I did not feel too well. After two weeks I set it back to 10. At 10, I maybe felt a little better and did quit snoring.

I think I should get the A-Flex feature out of the variables tonight and work on the pressure setting. I am ruminating on 7 - 10 auto (A-Flex off) or straight cpap 7, 8, 9, or 10.

Maybe the doc will call me this afternoon. It seems they don't schedule appointments for Friday afternoons and sometimes return a lot of calls.

Thanks for the indication on how to clear the data; I will do that tonight.

[Snoredog]

Does that PSG data include a titration table where your doctor indicated most events taken care of at 7 cm pressure?

I only have a summary but the sleep doc told me 7 cm took care of most of the events.

The same doc lowered my pressure to 7 recently. Later his technician frowned at this and told me she thought eventually I needed to get back to 10 (go figure).

I ran the straight cpap at 7 for two weeks, wife said I snored and I did not feel too well. After two weeks I set it back to 10. At 10, I maybe felt a little better and did quit snoring.

I think I should get the A-Flex feature out of the variables tonight and work on the pressure setting. I am ruminating on 7 - 10 auto (A-Flex off) or straight cpap 7, 8, 9, or 10.

Maybe the doc will call me this afternoon. It seems they don't schedule appointments for Friday afternoons and sometimes return a lot of calls.

Thanks for the indication on how to clear the data; I will do that tonight.

You need the get the actual copy of the PSG that was sent from the lab. I'd go by what the doctor was reading and not what some RT is saying. While it is nice to eliminate snoring if you can, sometimes you cannot eliminate snoring and doing so only creates more problems.

Snoring can also cause the machine to increase pressure, if you are at risk of CA's that increase can trigger more CA's which drives up the AHI. If you think the machine is smart enough to differentiate the difference between a obstructive event and central one you are only kidding yourself.

If you want to "know" who is right, your doctor or the RT, set your AFlex machine in CFlex mode with Cflex=Off, and pressure at 7.0cm and compare the AHI. Do the same with the RT's suggested 10 cm and compare. That way the machine only reports what it sees and it will ignore any snoring or events that may be causing it to drive up pressure.

In other words, you will be able to see how well you were actually doing on your old CPAP machine that didn't provide any data.

Your Aflex machine would still report AHI info in CPAP mode. Too bad you didn't have the EncorePro software to really see what was happening.

[roster]

The sleep P.A. just called. He babbled quite a bit, repeated himself often and even whined about how much liability they have when giving medical advice. Here is just a part of what he said.

- The AHI data from these machines is not accurate and I may not be having any apneas/hypopneas as they define them in the sleep lab.

- I should ignore the data and go by how I feel (well I feel crappy).

- He said my leak rate of 29 is too high and I might be losing pressure out my mouth. I told him that I was using a FF mask and that the mask manufacturer's specs call for a port flow that is in that range. He said 29 liters/minute is considerably high (What do I know? I don't have the manual for the latest version of the Hybrid shell that I am using, so I don't know their spec on this version shell.).

- I had to repeatedly ask him what I should do. He finally said change the pressure from 4-10 to min 7, max 10 and bring the card in a week for them to read.

For what it is worth.

[Wulfman...]

The sleep P.A. just called. He babbled quite a bit, repeated himself often and even whined about how much liability they have when giving medical advice. Here is just a part of what he said.

- The AHI data from these machines is not accurate and I may not be having any apneas/hypopneas as they define them in the sleep lab.

- I should ignore the data and go by how I feel (well I feel crappy).

- He said my leak rate of 29 is too high and I might be losing pressure out my mouth. I told him that I was using a FF mask and that the mask manufacturer's specs call for a port flow that is in that range. He said 29 liters/minute is considerably high (What do I know? I don't have the manual for the latest version of the Hybrid shell that I am using, so I don't know their spec on this version shell.).

- I had to repeatedly ask him what I should do. He finally said change the pressure from 4-10 to min 7, max 10 and bring the card in a week for them to read.

For what it is worth.

I can see why their liability would be high with THAT display of "intelligence".

Den

[Guest]

Den, you ancient wiseman. How DARE a sleep tech offer advice that doesn't meet your tried-and-proven standard of patient care. ;eyeroll

[roster]

Hit-and-run guests. Gotta love 'em.

[roster]

I reset the therapy screen to zero. I set the features to no flex, min pressure 7, max pressure 10. That shouldn't kill me tonight and I can check one night's data tomorrow morning.

Looks like tonight's hs football game is going to be a mudder. We desperately need the rain so I shouldn't complain. But, my daughter is the drum major, and the team is 3-0 and looking tough on both sides of the ball.

[gasp]

1. Now I see what you mean about those blue lights! Fortunately they did not bother me. Probably because the machine is on a bed tray well below the top of the mattress. They do light up the ceiling but that also did not seem to bother me.

I use them now as a homing device on those nights when I have to visit the restroom

2. The machine really does have a fairly loud whine when it is cycling the pressure up. This did not bother me going to sleep but it bothered me a little when I woke at 2:00 and 4:00. I do have a white noise machine with rain playing so the whine was masked somewhat. In the long run, I don't think the whine will be a problem but I may have to keep using the white noise machine.

I've had 3 machines. The first was so quiet! I drowned it so it died : ) The second had a whine like you describe so I turned it in and asked to try another right there in the DME's office to ensure it didn't whistle/whine. I now have a quiet machine. Just a hint of whistle on the exhale when at higher (above 9 or so ) pressure.

3. I have been using straight cpap at 10 cm. The A-Flex is set 4-10 cm, A-Flex comfort setting '2'. Wow! It is much more comfortable breathing.

I'm surprised they limited the upper range to 10. 4 is the minimum setting and mine is set at a 5 minimum to 15. In the past, I have used the 10 to 15 range on bad masks or bad asthma nights.

5. Aerophagia nearly eliminated. I wonder if I should go to comfort setting '3'? Mouth was still dry last night but not as bad as before.

I have mine set on comfort level 3 and it provides an appreciable (to me who has asthma) increase in exhale relief over level 2.

6. I am using the Hybrid mask version with reduced vent rate for auto machines. Data shows the system leak was 29.6 last night and I believe that is very good. Eh?

Correct me if I'm wrong, but isn't the leak rate solely tied to the mask versus the machine or machine/mask? I've experienced leakage rates anywhere from Comfort Gel around 14% to Quattro FF over 50%.

7. This morning I don't feel well, but I rarely have since I started cpap. I do feel lightheaded this morning and that is not usual.

Ask your doctor or RT, but it seems to me your pressure is too low. Expecially with your data showing "8. 90% pressure was 10 (setting 4 - 10). AHI was 25.1!"

I will go to the DME next week and have the card read. What do you recommend I do in the meantime?

Go sooner. Light headed isn't good. Let them know they need to fit you in. You said, "BTW, before the DME set up the machine, the RT claims she talked to the sleep doc for a long time trying to convince him to set the max pressure higher. He refused." I'd fire the doctor and get another! One that isn't in a power struggle with RTs.

Nice post by the way. Easy to read and reply to!

[RosemaryB]

My experience with my machine was that 8.5 is where my AHI is lowest. I started out with the machine set from 4-10 (if memory serves). Four was too low so the bottom was bumped up along with the top. When my max pressure was set to 11 or 12 on the autopap mode, I started registering centrals on my machine at 10.5, but the AHI went up after 8.5. (Some of those could have been centrals that the remstar didn't register as such). I did get some runaway pressures, too. After lowering the top range and increasing the bottom range over a long period of time, it turned out that a straight cpap of 8.5 was the place I had fewest apneas.

One of my points is that for some people there is a narrow margin between the best pressure for a person and one that starts causing centrals. (I didn't have all that many, though).

What Snoredog says makes a lot of sense to me given my own experience with it. I cast a strong vote for you getting both your sleep studies. When you get the software reader this will make a world of difference.

[rested gal]

The sleep P.A. just called. ---

Here is just a part of what he said.
---
- He said my leak rate of 29 is too high and I might be losing pressure out my mouth. I told him that I was using a FF mask and that the mask manufacturer's specs call for a port flow that is in that range. He said 29 liters/minute is considerably high

I don't think a leak rate of 29 is high at all with a Respironics machine. It's nice and low, imho.

[Snoredog]

Hit-and-run guests. Gotta love 'em.

They had to run, the alarm was sounding on the french fryer