Help with my new APAP

ballast949 · Post by **ballast949** » Mon Jun 27, 2005 5:25 pm

I convinced (didn't take much) my GP to prescribe a Respironics APAP with cflex and the DME finally got it in. Picked it up Friday and have slept with it for 3 nights now.

I have been using the Respironics BiPAP Pro 2 for a couple of months now and an inhale setting of 18 seems to give me very good results - most nights I am below a 5 AHI.

On the new APAP my initial settings were 10 to 20 cm for pressure with cflex set at 2. Looking at the card results for the first night, the pressure stayed at 10-11 all night even though my ahi was around 30 and the snore index was massive.

Thinking maybe I was just starting too low, I reset the pressure to 15 - 20. The card reader showed basically the same results. The pressure stayed right around 15 for most of the night - I had about 10 minutes at higher pressures. Again my AHI & Snore index were way higher than I would have expected and the APAP didn't seem to be adjusting.

Last night I upped the low end a little more, 16 - 20 and turned the cflex off. The results this morning were a little better, but the APAP shows no real signs of automatically adjusting the pressure in response to apnea events.

So, is my APAP just malfunctioning? Does it need to collect data over several nights before it really starts adjusting itself? If it won't auto-adjust, then what is the point in having it?

Any advice or pointers would be appreciated - tonight I'm going to set it in straight cpap mode at a pressure of 18 and see if I can't get a good night's sleep.

neversleeps · Post by **neversleeps** » Mon Jun 27, 2005 6:26 pm

Hi ballast-

I don't know if it works with your schedule, but the Chatting Live thingamajig is going on right now. I bet you'll find some answers there. (Or some theories anyway...)

rested gal · Post by **rested gal** » Mon Jun 27, 2005 9:16 pm

Does it need to collect data over several nights before it really starts adjusting itself?

No, it doesn't have to do that. I have no idea why it isn't responding for you. You've tried the right thing...upping the lower pressure. Sounds like going back to bi-level will be the best thing for you, unless someone has another idea.

Would be interesting to see if you would get the same lack of sensing what's happening in your breathing with another brand of autopap - like the 420E. But I know it can be difficult to try a lot of different machines.

IWannaSleep · Post by **IWannaSleep** » Mon Jun 27, 2005 9:56 pm

Ballast,

This may be obvious, but make sure your REMstar auto is set in the correct mode. The machine can be set to run in 4 different therapy types, including straight CPAP, CPAP with C-Flex, APAP, and APAP with C-Flex. Since you apparently know how to access the setup menus, check and make sure the therapy type is set to the code AFLE, which is the APAP with C-Flex setting. It sounds like you have it set on CFLE which is the code for CPAP with C-Flex.

If all the settings are correct then I would return the machine as it sounds like you received a defective unit. No reason to panic and switch brands, these things happen.

Let us know if you have any questions on the menus and settings or any other problems.

Ron

rested gal · Post by **rested gal** » Mon Jun 27, 2005 10:09 pm

I wondered the same thing you said, IWannaSleep...that it might be set in cpap mode...until I got to this:

The pressure stayed right around 15 for most of the night - I had about 10 minutes at higher pressures.

ballast949 · Post by **ballast949** » Tue Jun 28, 2005 1:55 am

Thanks Guys, No - I checked - it was in AFLEX the first two nights - I switched it to straight APAP last night, thinking that maybe the flex was making it hard for the machine to detect my breathing patterns. I will play around with it a little more, but I think I may just have a lemon - fortunately it is a rental, so if I don't find something, I'll make them exchange it.

I was just concerned that there might be some reason why the apaps don't react to the apnea events they are obviously seeing. The Encore report shows that it saw the events, but didn't try to adjust for them. At a starting pressure of 10, I would have expected it to push the pressure up to around 17-18. Looks like that is not the case, so it's probably defective.

ozij · Post by **ozij** » Tue Jun 28, 2005 9:02 am

Hi Ballast
Automatic machines are progarmed to respond to snores, apneas, flow limitations. If they discover one of those, they raise the pressure.

If I remember correctly, you were titrated for very very high pressure - wasn't it something like 23? - meaning your apneas are not responsive to lower pressures. Tiration, done in a lab by a human being can hazard raising the pressure more and more, till the obstruction opens, since the technician can tell it the apnea is the result of an obstruction, or not.

This is something automatic machines cannot do. Above a pressure of 10, auto makers a worried by the possibility that a non responsive apnea is a central apnea, (a cessation of breathing, without an obstruction) and they have various ways of handling that problem. The Remstar will try to give three slight nudges, and if the apnea doesn't respond, it will let it be. -SWS and Derek were discussing this some time in February. These nudges are not even pressure points, you'll find refrences to the technical data (the different machines' algorithms) in those discussions.

Basically, I think it possible that opening your obstructions needs the kind of pressure than a Respironics auto simply won't give. The Resmed doesn't rise above 10 at all, in response to apneas, (it does in response to snores and and flow limitations) the Respironics Remstar , ad said trys carefully and then lets things be, and the only one in which you can define the pressure in response to apneas is the PB 420E.

Sorry for not remembering why it was you wanted an auto, but it seems to me that in your case a bi-pap - which gives you very high pressure on inhale an lower pressure on exhale might be the better solution.
O.

mikemoran · Post by **mikemoran** » Tue Jun 28, 2005 9:44 am

Ballast,

You gave your AHI but do you ahve the breakout of AI and HI? My understanding is the ResMed Spirit algorythmn is much more agressive on snoring than the Respironics Auto. You may want to try one of the other brands.

john5757 · Post by **john5757** » Tue Jun 28, 2005 10:02 am

ballast949

What does the Flow limitation or Flattening looks like? While some units may have a harder time adjusting the pressure due to apnea I would think that the Respironics APAP should have responded to the snores. Some of the other Auto's can response faster to some events. How is your leak rate and if it is high that could effect the machine ability to adjust the pressure.
It may all be possible that a Bipap may be better for you.

rested gal · Post by **rested gal** » Tue Jun 28, 2005 12:25 pm

ozij mentioned:

the only one in which you can define the pressure in response to apneas is the PB 420E

ozij, you made a lightbulb go on over my head! Thanks! Don't know why I didn't think of that, since the very scenario Ballast is describing was the reason I sent my 420E (which I dearly loved!!) to someone else to try, over a year ago. That person was also having apneas that his rather old model auto was not responding to.

He was able to turn up an advanced setting on the 420E ("maximum command for pressure on apnea") to override the algorithmic safety throttle you mentioned... the one that is built in, in different ways, into autopaps.

An aside here: most people do not need to, nor should they, mess with the "advanced" settings on a 420E autopap. It works fine at the factory default "advanced" settings for most.

Ballast, that's what I'd do - try the PB 420E autopap, so you can experiment with the advanced settings to see if that particular autopap can roll up its sleeves and go to work on those persistent apneas. If it doesn't...you can always go back to bi-level treatment.

2listless · Post by **2listless** » Tue Jun 28, 2005 1:41 pm

I am not an authority here but you were put on a Bi-Pap for a reason....which you did not mention. A Bi-Pap is a seriously better machine than an APAP with CFLEX. I, personally, would stay with a Bi-Pap. If you are having trouble with your Bi-Pap, then you need to see your sleep doctor and have a little "chat." With your titration levels, I would be seriously wary of trusting any Auto machine ....... if you stand a chance of hitting the upper limits and not being corrected, I personally feel that you are playing in dangerous waters. The Auto is responsive to all kinds of things..not necessarily to what your body is actually doing. The accuracy of the snore index is very questionable. You would get a better idea if you used a tape recorder. All kinds of ambient noise can affect it. In a just completed visit with my Sleep Doctor, he told me that various masks can and do affect results with certain people. I was told not to use the very famous and well-liked Activa....not because it is a bad mask but it is a bad mask for me. On the Auto, I get consistently high readings with it. With either of my other 2 choices my average drops to 5-8 from 12! If you have questions about using the auto instead of the Bi-Pap, PM Derek. He can explain it to you very well. My honest recommendation is to stick with your BiPap. If you are still having trouble, have a serious chat with your doctor....you might qualify for a VPAP.....it is the gold standard. I am on the Auto with CFLEX and the doctor and I are under serious discussion for a Bi-Pap and my levels are a third of yours. From my heart, I am asking you to proceed cautiously!

Guest · Post by **Guest** » Tue Jun 28, 2005 1:52 pm

[quote=] If you have questions about using the auto instead of the Bi-Pap, PM Derek. He can explain it to you very well. [/quote]

Maybe explain it to us here so that we can all learn too?

rested gal · Post by **rested gal** » Tue Jun 28, 2005 2:47 pm

In the meantime, the Search button above can be useful with a search for....

key word: autopap
author's name: Derek

While doing that kind of search, another author's name that is absolute "must reading" when it comes to how autopaps work: -SWS

(His nickname does have a hyphen in front of it.)

wading thru the muck! · Post by **wading thru the muck!** » Tue Jun 28, 2005 3:09 pm

Ballast,

You've gotten many good suggestions to your perplexing problem. One other thing that I might suggest you look at is the leak graph. I see from you picture that you use a FF mask. These are prone to be leaky and I have found that too many leaks can reduce an auto-paps ability to correctly prevent A/H.

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