Some Basic xPAP Questions-(and a little venting)

Hello,

I'm new to CPAP (since Aug 16) and new to this forum. Diagnosed with Mild Sleep Apnea. No Apneas during sleep study, but average about 24 hypopnias per hour. I've had my struggles with mask and and manchine throughout the process like alot of what I've read.

I can explain more if necessary, but at this point I'm using Respironics Remstar BiPap Auto M series with BiFlex (DS-700) with their humidifier. Went from a Resmed compact, to a Resmed Escape II with EPR, to this one because I had difficulty tolerating standard CPAP and also to gain max comfort (I'll just add here that I work in a safety related aviation field -not a pilot- where my medical certification was on the line and needed to get up and running as quickly as possible - even though I was not prone to falling asleep on the job and no lives were endangered-and my diagnosis is "Mild"). I got to the point where I could say that I am tolerant and use the XPAP therapy, and got a satisfactory result from a follow up pulse ox test plus follow up report from my doc, which satisfies the powers that be. That doesn't necessarily mean I'm getting max comfort and benefit from my therapy though and there is clear room for improvement.

I won't go into the frustrations of dealing with my Doc (who I like generally) and his sleep lab (he has some interest in it -which was also the original DME provider of the Resmed Products) to changing to an independent DME. Suffice to say the learning curve is huge for a newbee on all fronts as you all already know.

Here's some additional info to add to my machine noted above: I started with the Swift II which is what I was titrated with at a pressure of 8. After the next two days at home I couldn't tolerate the direct pressure into the nostrils plus the irritation to my upper lip and nasal cartlidge from the retaining bar on the Swift. I felt it would be more comfortable breathing the ambient (as I know I wrongly call it) positive air pressure from within the cavity of a nasal mask. I was right, for me at least. I went to a Respironics Comfort Gel, then a ResMed Activa, both of which I can use more or less. I feel I get less overall leak from the Active and mostly use it.

As I said, my titrated pressure is 8. My auto is set for min-4, max-14. I use the BiFlex set at 1, though I started at 3. My DME rep says I don't need the ramp since the machine starts at 4 and comes up after I fall sleep according to my needs. I use the Respironics humidifier at 2 and occassionally 3 (an aside - I think I liked the ResMed humidifier better as it seemed to have finer tuned settings options and the whole Respironics construction of it's two piece water tank is convoluted. But overall the Repironics machine seems good - I ultimately went to it because I was convinced by some of my own research and discussions with a DME that it would provide for a more natural breathing pattern and feel more natural overall than the ResMed) - it did seem better than the Escape II with EPR mode and I couldn't be on a goose chase to compare it to a similar ResMed auto - so here I am and where I intend to stay with the machine part of this adventure.

Sorry for more background than I intended to give, but here's finally my questions:

1. What does the average AHI mean in the user accessible data screen? I asked Respironics if it was the corrected or uncorrected number of events and they responded that they are "events." Thanks Respironics! If they are uncorrected events, why is the machine not correcting them? If they are the total average of actual events, where I'm now down to a little less than 5, starting from 9.4 on the first night with this machine, why do I need the machine?

2. What is an "acceptable" leak rate. I understand the concept and can check the charts. Since some mask leakage is "normal" I'm told, is there some amount above the built in mask leak to look for? The first night with this machine I was at 39.3 L/Min and now around an average of 28-31ish L/Min which seems close to the mask leak rate at pressures of 8-10.

3. I thought that a BiFlex level of 3 would reduce pressure the most on exhalation and therefore be most comfortable. Why does it seem a bit more comfortable using a level of 1?

4. Resprironics told me they cannot provide me the clinicians manual for my machine or the software for the data card. My DME said they will as a courtesy read the data card every 3 months and forward the report to my doctor. But alot of people on here seem to have access to the software. Is there a way to get it - either the software or provider's manual, or at least better definitions of the user screen info?

I, like many on here, need to be active in my therapy. It seems completely unreasonable and way short of any appropriate standard of care, that the medical profession would send you home with a straight CPAP and just let it blow air down your throat till when??? They decide you need to see them again to follow up? Meantime, you don't know if you're being helped or hindered by the therapy.

Thank you for your patience in wading through my post. Any answers or comments on my saga would be greatly appreciated. If I can provide specific information to help please let me know. It's nice to know there are so many helpful people like yourselves who have gone before me and are willing to help.

Joe

Joe,
I am not a medical professional but believe you really need to be proactive in your therapy. Further, I believe you may reduce your ahi by bumping up your EPAP pressure from 4, closer to your titrated pressure. Unless you are extremely small build you may feel like you can't breath at 4 and should you fall to sleep any events you have won't likely be treated.

Get as close to your titrated pressure as comfortable for you. Raise your IPAP to about 14. You may even find that you will need this extra head room.

This is probably THE most comfy machine when setup correctly. If you are having trouble exhaling my guess is that it's NOT setup correctly. 1st clue is starting out at 4cm, untrained RT's think this is OK.

Search the forum for how to setup a BIPap.

Is this machine set up as a bipap? or just an auto?

Keep trying different masks until you find one that suits you. If your DME won't do that for you, there are some free test drives going on for a variety of masks:

HYBRID – by pjwalman
viewtopic/t33434/Hybrid-TestDrive-Continues.html

SMALL LIBERTY – by fortomorrow
viewtopic/t35474/ResMed-Mirage-Liberty-Test-Drive.html

LARGE LIBERTY – by echo
viewtopic/t35486/Large-Liberty-test-drive.html

NASAL AIRE II – by Babette
viewtopic/t30639/The-Return-of-the-Grea ... Drive.html

Mask Roulette – thread for swapping masks
viewtopic.php?f=1&t=19546

Good luck and welcome to the forum!!!
Babs

SleepyJoeMS wrote:Hello,
<snip>

1. What does the average AHI mean in the user accessible data screen? I asked Respironics if it was the corrected or uncorrected number of events and they responded that they are "events." Thanks Respironics! If they are uncorrected events, why is the machine not correcting them? If they are the total average of actual events, where I'm now down to a little less than 5, starting from 9.4 on the first night with this machine, why do I need the machine?

Average AHI is yor hourly average for the night. There really isn't a corrected vs uncorrected count only detected events that didn't get prevented. The Auto tries to pre-empt events. Autos look for symptoms of looming events such as reduced airflow (called flow limitations or hypopneas) and also listen for snores & if these things are detected it steadily over time raise the pressure. If you have your starting pressure set too low, the machine may miss preventing obstructive apneas and these will show in your nightly average. A setting of 4 CMs as the start pressure really is too low.

2. What is an "acceptable" leak rate. I understand the concept and can check the charts. Since some mask leakage is "normal" I'm told, is there some amount above the built in mask leak to look for? The first night with this machine I was at 39.3 L/Min and now around an average of 28-31ish L/Min which seems close to the mask leak rate at pressures of 8-10. As you can already see, leaks are hard to avoid. I would guess that 20% of the fixed leak rate is a possible upper limit for accidental leaks.

3. I thought that a BiFlex level of 3 would reduce pressure the most on exhalation and therefore be most comfortable. Why does it seem a bit more comfortable using a level of 1? Biflex and C-Flex do have a side effect & that is accelerated airflow as the feature finishes its intervention. This can cause aerophagia for some people or plain discomfort. Running BiFlex or CfLex at 1 is not uncommon.

4. Resprironics told me they cannot provide me the clinicians manual for my machine or the software for the data card. My DME said they will as a courtesy read the data card every 3 months and forward the report to my doctor. But alot of people on here seem to have access to the software. Is there a way to get it - either the software or provider's manual, or at least better definitions of the user screen info? Am sure someone can email you a pdf copy - I don't have it for that machine

I, like many on here, need to be active in my therapy. It seems completely unreasonable and way short of any appropriate standard of care, that the medical profession would send you home with a straight CPAP and just let it blow air down your throat till when??? They decide you need to see them again to follow up? Meantime, you don't know if you're being helped or hindered by the therapy. Hence we have this great site

Thank you for your patience in wading through my post. Any answers or comments on my saga would be greatly appreciated. If I can provide specific information to help please let me know. It's nice to know there are so many helpful people like yourselves who have gone before me and are willing to help.

Joe

Joe - good luck - you have come to the right place. DSM

the software is encore pro (old professional edition) - you need 1.6 or higher - or encore viewer 1.0 - if you are using vista you need encore pro 1.8 or encore viewer

cpap.com sells the bundle of encore viewer and the card reader

the card reader is a special kind - you can search the forum for further information on these - you need Mako DT 3500 card reader - says infineer on the front

Joe,
Why is it that you were put on a bipap? What was the problem with all the other machines?
It just seems strange that for a pressure of 8cm they would put you on a bipap.

ps.It doesn't sound like it is setup correctly either. Please tell us what is in the setup menu.

Hi Joe, and welcome to the message board!

SleepyJoeMS wrote:1. What does the average AHI mean in the user accessible data screen? I asked Respironics if it was the corrected or uncorrected number of events and they responded that they are "events." Thanks Respironics! If they are uncorrected events, why is the machine not correcting them? If they are the total average of actual events, where I'm now down to a little less than 5, starting from 9.4 on the first night with this machine, why do I need the machine?

It means those were events that sneaked through despite treatment.

Probably the EPAP is set too low down at the 4 cm's you said the machine was set at. Even though the single pressure that was found at your sleep study is considered fairly low .. that 8 you were prescribed, it may be that it really takes 8 , or close up to it, to keep your airway open well.

Bear in mind that if your BiPAP Auto is set to operate in auto bilevel mode (and it sounds like it is, since the DME told you it would find the pressure needed) that machine is going to start out each night using just 6 cm's for inhaling (IPAP) and 4 cm's for exhaling (min EPAP.) Even though the max IPAP is set higher, the machine is going to START each time using only 2 cm's more than whatever the EPAP has been set for. So, it's starting out very, very low with both pressures for you.

"Events" may happen for you more quickly than the machine can adjust upward for them, so it may be playing catch up a lot instead of being able to prevent some of the things that are sneaking through. In other words, while the DME was technically correct that it will adjust the pressures automatically, he/she probably doesn't realize that it might not be able to adjust them soon enough to prevent things as well as it could if the EPAP were set up closer to your prescribed pressure of 8 .

If it were me, and I'd been prescribed a single pressure of 8 , but was going to use the BiPAP Auto ... I'd probably just set it in bilevel mode (I'd turn off "auto") and use it at IPAP 10 / EPAP 7 or IPAP 10 / EPAP 8 .

If I were going to use the machine in "auto bilevel" mode, I'd set min EPAP at 7 (or 8 ) and max IPAP at 20. Don't be alarmed by the "20" for "max IPAP." Even with "auto" turned on, the machine is always going to start out using only two cm's more IPAP than the EPAP. And IPAP is not going to go up anywhere near 20 for you, based on what you said the machine's data has shown for you, so it doesn't matter that that setting would have a lot of UNused pressure available up there. It's not going to go anywhere close to that for you in "auto bilevel" mode.

Either way (in just "bilevel" mode, or in "auto bilevel mode" ) I'd set Bi-flex however it felt smoothest. I like it at "3" myself, but that's a comfort feature and everyone's different. Some would turn off Bi-flex altogether, others would use whichever Bi-flex setting felt nice. It's an individual preference.

There's another "comfort" feature than can be used instead of Bi-flex on that machine. It's called "Rise Comfort", and it governs how fast (in milleseconds) the machine will move up to the IPAP pressure when you start to inhale. But that feature is not available if you have Bi-flex turned on. Bi-flex has to be turned off for the "Rise Comfort" setting to even appear further along in the therapy setup menu.

You can't use both those at the same time (Bi-flex and Rise Comfort.) It's a one-or-t'other thing. Personally, I like Bi-flex better, but it's worth trying all the "comfort" settings out to see what you like. If I did use "Rise Comfort", I like it set for as long as it would go... "3", or it feels like too abrupt a switch to the higher pressure when I started to breathe in again.

SleepyJoeMS wrote:4. Resprironics told me they cannot provide me the clinicians manual for my machine or the software for the data card. My DME said they will as a courtesy read the data card every 3 months and forward the report to my doctor. But alot of people on here seem to have access to the software. Is there a way to get it - either the software or provider's manual, or at least better definitions of the user screen info?

If you'll PM me your email address, Joe, I'll be glad to send you a PDF of the clinician manual for your machine.

It's good to see yet another person who plans to be proactive about their treatment. Most are pretty much left to sink or swim by the DMEs and the doctors. You found your way to the right message board for learning how to take control of your therapy.

Here's a link to tuck away... some of the links within it might come in handy:

ALL LINKS by rested gal
viewtopic.php?t=17435

My edit - corrected wrong URL. No words changed in the post.

jules wrote:Is this machine set up as a bipap? or just an auto?

As I understand, it's set up as an auto right now, with a low/high pressure of 4/14. My titrated pressure was 8 at the lab.

so you aren't using it as a bipap - so you aren't getting "real" exhale relief that a bilevel machine can provide

so your question about getting exhale relief - well ----- you need to get into the bipap mode or the auto bipap mode to get some GREAT relief, not just use biflex

jules wrote:so you aren't using it as a bipap - so you aren't getting "real" exhale relief that a bilevel machine can provide

so your question about getting exhale relief - well ----- you need to get into the bipap mode or the auto bipap mode to get some GREAT relief, not just use biflex

Well, actually and here's where I get confused between auto and bipap, as many times as it's been explained to me... isn't the low and high pressure settings making it bipap?, and it's set to auto titrate? So maybe I'm wrong and it is in an auto bibpap mode. But my rep said to set the biflex to 1,2 or 3 depending upon what feels best to me. I can check and find out how they set it for sure though.

The BiPAP Auto can't be used as just an "autopap." It will always be a bilevel machine with separate inhale (IPAP) and exhale (EPAP) pressures. IPAP and EPAP can be set at the same pressure, to make it behave like a plain cpap machine at a "single" pressure. But it can never operate in just "auto" mode. It will always require setting those two separate inhale/exhale pressures.

The way Joe's machine is set up now sounds like it's set for "auto bilevel" mode. Meaning, it's in "bipap" mode with EPAP set way down at 4 (!!) and the maximum IPAP it can go to if needed is set at 14. EPAP and IPAP can vary as needed like an autopap, but it's two pressures doing the varying. Not just one pressure varying, as in an autopap. The IPAP and EPAP can vary independently of each other... to a point. In auto bilevel mode, they will stay at least 2 cms apart from each other. And they can never get farther apart than the difference between the EPAP/max IPAP setting (or 8 cms apart at the most during the "varying" moves.)

In auto bilevel mode, that machine is always going to start out using just 2 cm's more IPAP pressure than whatever the EPAP is set for.

So, Joe's machine is going to start out each night using only 4 for exhaling and 6 for inhaling. Way too low for both pressures to start out at, for effective treatment, imho, but I'm not a doctor.

At the risk of sounding like a broken record....

If it were me, and I'd been prescribed a single pressure of 8 , but was going to use the BiPAP Auto ... I'd probably just set it in bilevel mode (I'd turn off "auto") and use it at IPAP 10 / EPAP 7 or IPAP 10 / EPAP 8 .

If I were going to use the machine in "auto bilevel" mode, I'd set min EPAP at 7 (or 8 ) and max IPAP at 20.

I'd set it in Auto mode like RG suggests and let it find your pressure. It obviously isn't in that mode with AHI=24.

4 cm starting pressure is too low, you will be stuffy and starving for air that low of pressure.