Newbie got machine last night, asking for some settings help

[GaryGarland]

Hi All,
I had my study 15 days ago, and finally was able to get an appointment (and then RX) with my new ENT yesterday - and after begging and jumping through hoops I was able to get a machine (insurance quasi-approved, i'm on the hook if they don't, but hey, it's worth it to finally sleep!)
Anywhoo, during sleep study, i scored a "56" with 60 being i think ultra-severe? (i'm 41, and heavy though not huge). my oxygen had dropped to 80, etc., and at the study they said they recommended a CPAP pressure of 14. yeah, i know, not teensy.
anyway, got my shiny S8 Autoset II with h4i (machine only recognizes 3i, but that's okay) - it was the first 4i my tech had seen.
She set the machine as a CPAP at 14. so naturally, i hacked the machine and enabled Autoset, and i chose a range of 9 to i believe 15. Using Nasal Swift LT, humidifier on 2nd click.
I also set the leak detection on, which disables the smartstart (bummer). i was thinking of lowering the lowest pressure.
I"m at the office, but from memory my AI was roughly 6 and HI 8, but
1) i can be wrong (though i think close), and
2) while trying to fall asleep/back to sleep i was screwing around a little and holding my breath, causing the machine to blow a bit harder (possibly reporting those)
My respiratory tech was a real sweetheart, but only knew the basics about the machine (hey, she probably has to set up 5 different brands). Can anyone recommend other settings based on what i said? how about the reader and software -- worth it?
personally, i think i have one of the top "setups" available - i'll probably get a full face mask for when i have colds, and possibly a fleece wrap for the tubing. Any other advice?
Thanks very much - I slept only fair last night (acclimating) but at least i didn't snore and my pregnant wife got her first decent night's sleep in months. anyway, thanks for any suggestions...

[OutaSync]

Presuming that your prescription was for 14, why don't you try the way they set it up for at least a week and see how you do. Changing it to APAP with such a restricted range won't tell you much unless you have the software. Try what they prescribed first.

Bev

[GaryGarland]

Thanks Bev; the little I understand (and thus the newbie status) is that if i go with CPAP 14, the machine is acting "dumb" and constantly plunking out at that range - if i go with auto a bit above, but even better below, the machine should be able to supply just the right amount of pressure needed - and probably 14 only for certain events - at least that's my guess. the little i've read (and even less that i understand) is that the lower pressures provide better sleep comfort, perhaps less drying, etc.
i saw a post somewhere that said consider going roughly 3 or 4 above and below - i was planning on that - altneratively the machine's stock setting is 4 to 20 - wide range and from what i read, it takes a while to go from a very low setting for it to increment up to where you need to be; if you stay closer to your real range the machine will gradually react "quicker"
sigh - so confused.....!

[Slinky]

First off, double-check w/Resmed about the Humidaire 4i for the Resmed S8 II AutoSet. When I asked them about the Humidaire 4i for the Resmed VPAP Auto (new in January 2008) they said no to the Humidaire 4i, that I needed the 3i, the 4i was for the new (July 2008) Resmed VPAP Auto 25. Our local DME suppliers and their RTs don't always "know" the truth of the matter.

Second, you've got a h*ll of a good APAP there. I had its predecessor, the Resmed S8 AutoSet Vantage, and love it but have since been switched to VPAP bi-level auto. I well know what it is like to get a new toy! And neither am I the most patient of patients plus I do like having some control over my therapy. BUT - I would REALLY suggest that you put her back in CPAP mode and stay in CPAP mode until you're acclimated to the CPAP and mask and you have your Leak rate down to 24.0 or less on a CONSISTENT basis, the closer to 0.0 the better.

WHEN you have your Leak rate CONSISTENTLY under 24.0 OR PREFERABLY LESS is the time to play around w/your scripted pressure and/or auto mode if you must (of course, we must, its "our APAP and "our" therapy and "our" new "toy!). Then I would suggest 2 cms under your scripted pressure and 2 cs above your scripted pressure as the place to start. Always keep in mind that an in-lab PSG is more sophisticated than the most sophisticated APAP whilst the APAP has the advantage of our sleeping at home in familiar surroundings so the two can be mutually complimentary.

WHEN YOU DO make a change, make ONLY ONE CHANGE AT A TIME and STAY at that change for ONE FULL WEEK before deciding, based on the weekly averages of your data, to make another ONE change at which you would also STAY for one full week before deciding on that week's averages what other, if any, change you want to make. AND a mask change equals ONE change, just as if you had made a pressure setting change.

Its not as much "fun" as "playing" w/your settings every night or so - BUT - it is the most logical, efficient and healthiest way to make any changes.

[GaryGarland]

good replies, thank you - so what did i do last night? i took the advice to heart...and then gently disregarded it - i set the machine for 4 lower and 15 higher - then when i awoke at 1:30 a.m. i saw i had tons of events!!!!! yikes! so, i then switched it to cpap mode with my pressure of 14 - and then slept intermittently the rest of the night (even with a single rhino-stopping tylenol pm over the counter) - it felt like the pressure was blowing the nasal pillow out of my schnoz. i am getting slightly more "used to" the mask and head harness.
i think my best bet will be to get the software and reader and see what's really going on - to the extent i can. i will say my nostrils just are not loving life right now - feel kinda sore, but i'm sure i'll acclimate.
i'm going to do a new post asking about the software and recommended hardware interface - i also do plan to get the fleece tubing cover - any other suggestions, aside from "hey, stop playing with all the buttons?"
(BTW, i haven't taken that advice since i was about 3 - and i have all the broken electronic devices to prove it!)

[sleepycarol]

I don't have the Resmed machine but the M series apap. But I do have some suggestions.

Get something to help your nose in the transition. It will thank you. Ayr Gel is very good about soothing a very tender nose as well as lanolin based ointments. They can also help with obtaining a seal. As far as treatment goes this is a minor expense and if you don't use it all there is always cold time when you have a raw nose.

Padacheeks has some awesome headgear covers to help keep the straps from rubbing. Karen is a member here and great to work with.

Pursleep can also help with transitioning into a deeper sleep according to many (me included). He will even send you free samples (the last I knew his trial of samples was still open). All it takes an email to Bret (sleepguy).

These can make your therapy nicer and gives you something to play with besides the machine.

If you make too many changes in a short amount of time (your pressure settings, ramp, epr, etc.) you won't know what is really working and what is a no go. We all have bad nights -- it is a fact of life. So you won't know if it is because it was one of those nights or what change triggered the bad night. That is why it is suggested to wait a week before changing anything else and to make only one change at a time.

[cpapqueen1]

You can use the 4i with the s8 unit. For the nose, try changing your size of the nasal pillow down a size. THe size of The LT pillows can be deceiving too some.

[GaryGarland]

Thanks so much for the suggestions! I've requested samples of the pursleep and will check out the pads - then i'll need a few bumper stickers, increase the ram in my S8, add turbo, maybe a joystick....naw, the pads seem like a great idea, and i never considered "aromatherapy" before - but then again, i never thought i'd sleep with air blown up my nostrils with tubes, either - go figya!
Thanks again!!!!!

[sleepyangler]

First of all, if you have been titrated at 14cm the auto pap setting of the resmed isn't going to be very effective for you. The resmed apaps use what they call the A10 algorithm to vary the pressure based on your breathing. My understanding is that the A10 basically stands for the fact that the machine will not respond to an apnea if the current pressure is already at 10cm or higher. It will still respond to hypopneas and maybe some other flow restrictions but if you experience a true apnea when the pressure is above 10cm the machine will not increase the pressure. It is an attempt to prevent the machine from chasing central apneas with ever increasing pressures. There are other apaps that will allow you to change the pressure level at which the machine will stop chasing an apnea but unfortunately you can't do that with a resmed. At best, you are going to have to determine the pressure which eliminates most, if not all apneas and use that as the min apap pressure. Since you were titrated at 14cm and assuming that pressure is even close to correct, you will most likely end up with a very narrow apap range before you will be able to get the AI portion of your AHI reasonably low.

Second, since you are using a resmed swift interface with the resmed apap, make sure that you have the correct mask selected in the setup menu. Once that setting is correct, the leak rate you are shooting for is zero, as the machine takes the mask leak rate into account. Once you have the software, what you are really looking for is a fairly straight line for the leak graph.

[Wulfman]

First of all, if you have been titrated at 14cm the auto pap setting of the resmed isn't going to be very effective for you. The resmed apaps use what they call the A10 algorithm to vary the pressure based on your breathing. My understanding is that the A10 basically stands for the fact that the machine will not respond to an apnea if the current pressure is already at 10cm or higher. It will still respond to hypopneas and maybe some other flow restrictions but if you experience a true apnea when the pressure is above 10cm the machine will not increase the pressure. It is an attempt to prevent the machine from chasing central apneas with ever increasing pressures. There are other apaps that will allow you to change the pressure level at which the machine will stop chasing an apnea but unfortunately you can't do that with a resmed. At best, you are going to have to determine the pressure which eliminates most, if not all apneas and use that as the min apap pressure. Since you were titrated at 14cm and assuming that pressure is even close to correct, you will most likely end up with a very narrow apap range before you will be able to get the AI portion of your AHI reasonably low.

Second, since you are using a resmed swift interface with the resmed apap, make sure that you have the correct mask selected in the setup menu. Once that setting is correct, the leak rate you are shooting for is zero, as the machine takes the mask leak rate into account. Once you have the software, what you are really looking for is a fairly straight line for the leak graph.

I strongly concur with what sleepyangler said. You've got the wrong machine to use in Auto mode if you're having Apneas above a pressure of 10. You're going to have to use it in CPAP mode.

Den

[GaryGarland]

Thanks fellas,
after reading the posts, i put the machine back to 14 and CPAP mode - and once i realized i was overtightening the straps on the LT my comfort went up and leaks have been down to 0% for the last two nights.
i still need to deal with the straps shifting during sleep, but i'm getting there.
also, as i reduced the pressure on the streeps, my AI and HI seem to have gone down (whew) - they had been up to 11.6 and 11.7 respectively, now they're something like 2 each.
funny, i find i prefer a 5 minute ramp versus 20 minutes or so - and even with a quasi stuffed nose i can breathe well with the machine - whooda thunk?
Thanks again!!!!!

[Wulfman]

Glad to hear you're making progress, Gary.


Den

[Hawthorne]

Gary - you have had a lot of good help here. You have put those suggestions to use, along with your own experiences, and are now seeing good results! I'm glad for you!

All of us have bad nights once in a while and, I'm sure you will too, but it sure looks like you have come a long way in the short time you been posting. That's great!

Keep asking if you have questions. Soon you'll be making suggestions, from your own experience, to others.

[GaryGarland]

Thanks for the good words - i saw there was a bit of nastiness (didn't see the originating posts -- and i'm quite fine with not seeing them!) - i saw someone mention (and i heartily agree) how fast the learning curve is - i got my machine 6 days ago - since then, i fairly well understand each setting (not saying i clinically understand some of the significance) and absolutely amazing how fast a body can acclimate to the machine - i still wanna get the software so i can be a graph reading maniac. the site (and community here) is great and really appreciated!

[Hawthorne]

That's great Gary. You're right, this community is a huge help. You're right to ignore the nastiness. It comes and goes.

I am a data "nut". I love seeing my data every morning and seeing how the therapy is going. Sounds like you are into that as well. It really helps in understanding and in guiding any changes.

Keep us posted! Have a good one!