A little guidance please

TonyG · Post by **TonyG** » Tue Jan 21, 2020 8:03 am

Last night was my first night using a ResMed machine. Have for the last 6 years used Respironics. The first nights results are completely out of character and I am trying to get a handle of what could be the primary issue. As you can see almost all of my events are centrals. Pressure range set 9-20 with an EPR at 2. For the most part of the last couple of years I had been using fixed pressure at 9.5 or 10 and the 95% shown on this night appears within that range. The leak rate shown is double my usual so don't know if that plays a part.
I am sure there is probably a simple solution but I don't consider myself anything of an expert on these machines. This is also my first experience posting a report so please be nice if I screwed up. My usual ahi with the Respironics was in the 1-2 range although winter seems to bring out some sort of bogeyman and it goes up a bit. Hopefully someone has a simple answer. Any guidance would be greatly appreciated. Thank you.

Pugsy · Post by **Pugsy** » Tue Jan 21, 2020 8:35 am

Were you asleep or awake when those centrals were flagged?

harrywr2 · Post by **harrywr2** » Tue Jan 21, 2020 9:40 am

If your mask type setting is incorrect then the leak rate and pressure delivered at the mask will be incorrect. Resmed's calculate expected vent leak based on mask type and subtract it from the leak rate. As your post includes the pie chart the settings for mask type are not shown.

TonyG · Post by **TonyG** » Tue Jan 21, 2020 9:50 am

First of all thanks for taking the time to reply.

Pugsy: not sure. Definitely some of those centrals were awakes junk. Had trouble falling asleep and I am sure I was awake after 6am. Also awakened during the night but unsure of the time. No doubt they may have been during that time frame. Wit the PR1 my main problem was with hypopneas. I would have some centrals from time to time but they were mostly junk. I must say I had a bit of anxiety last night considering the switch to a new brand of machine after having been on PR all my time on PAP. Someone suggested to me to reduce min pressure and epr by 1 as a start. Would you agree?

Harry: mask setting is correct.

Pugsy · Post by **Pugsy** » Tue Jan 21, 2020 10:11 am

I don't like making 2 changes at one time because if there happens to be dramatic differences in results we don't know which change might have been the cause of the different results.

I doubt your centrals are related to the pressure but it wouldn't hurt to reduce the minimum pressure.

Since you know for sure you were awake for a good chunk of the night I am thinking that there's a strong possibility that the bulk of those centrals are SWJ false positive centrals.
So I am doubting they are related to EPR being used which is what we might first think. Wouldn't be impossible though but again wouldn't be impossible for the bulk of them to be SWJ either.

Did you use the Flex relief on your Respironics machine? They aren't exactly the same in how they go about giving the exhale relief.
If you didn't use any Flex relief or maybe setting of 1...the difference between it and EPR of 2 might (stress the might part) be a factor in some centrals. It's rare though.
So what was the Flex setting on the Respironics machine?....and which model machine? System One???? older???

Not sure why the leak rate might be so different especially considering how Respironics reports the leak numbers and how ResMed reports them. If anything the ResMed leak numbers should be less I would think since ResMed only reports excess leak and not total leak like Respironics does. I might want to see some Respironics leak reports to compare the two but I would put that on the back burner for now. It's not a critical issue.

I am more inclined to chalk it up to first night with a new machine jitters.

Heavy on the SWJ stuff.
But the algorithm for the auto adjusting mode is different and from my own past personal experience with both brands in auto mode...I think you could probably get by with less minimum pressure just from a therapy effectiveness standpoint.

Your choice as to what to do....one change or two changes (or even no changes) if you wish but I would make one change only if it were me and I think that change would be in the minimum pressure unless your Flex setting was markedly different from EPR at 2 setting. It would be a small change though if for no other reason than if you drop the minimum too much at one time it might not be very comfortable in terms of air movement. I have been there and done that myself which is why I mention it.

palerider · Post by **palerider** » Tue Jan 21, 2020 10:39 am

harrywr2 wrote: ↑
Tue Jan 21, 2020 9:40 am
If your mask type setting is incorrect then the leak rate

No, it won't.

harrywr2 wrote: ↑
Tue Jan 21, 2020 9:40 am
and pressure delivered at the mask will be incorrect

Not enough to notice, only a fraction of one cm.

harrywr2 wrote: ↑
Tue Jan 21, 2020 9:40 am
. Resmed's calculate expected vent leak based on mask type and subtract it from the leak rate. As your post includes the pie chart the settings for mask type are not shown.

No, they don't.

Please stop.

Pugsy · Post by **Pugsy** » Tue Jan 21, 2020 10:47 am

An incorrect mask selection choice on a ResMed machine doesn't really impact much of anything in terms of pressures or leak numbers.
The differences are so small they are insignificant.
Been there and done that myself...wrong mask chosen and when finally realized and corrected....nothing changed that I could see or tell anywhere.

palerider · Post by **palerider** » Tue Jan 21, 2020 11:02 am

TonyG wrote: ↑
Tue Jan 21, 2020 8:03 am
. The leak rate shown is double my usual

Yo can't compare the leak rates between Resmed and respironics, the machines report it differently. Respironics shows *total* air that escapes from the mask in any way, Resmed calculates what the baseline vent rate of the mask is, and only shows *excess* leak.

Please review how to format your charts, we don't need mask pressure, but we do need snores and flow limitations. Instructions are in the first post, labeled READ THIS BEFORE POSTING.

I'd actually recommend *raising* the min pressure some, in order to save off the events that are causing pressure to jump, but let's wait a couple days, and see what things look like after you're more used to the new machine.

TonyG · Post by **TonyG** » Tue Jan 21, 2020 11:34 am

Pugsy: To answer your questions

- I did use flex on the Respironics (System1 561ca ) set to 3 lately . Had been using 2 for a long time beforehand but found 3 better in the winter . 2 works fine with the P30i but 3 is more comfortable with the P10. So.. depending on which mask I use.etc etc. (We all have our shortcomings)
- I should point out that for the longest time now I had been using straight CPAP at 9.5 or 10 because I always got better results then with APAP on the PR. Thought I would try APAP again with the new machine just because . My 90% was in that range when I did a trial recently on that machine
- the snores may be imaginary. I have never had any faith in the reports because my wife says I don't snore but I do have a problem with congestion so maybe its just ickies squiggling around causing the vibes we don't actually hear. My story and I am sticking to it. My PR ones use to indicate some mask leaking but I never felt any. I know I do mouth breath some though. Tried the F30 last winter and it eliminated all snores but the rest of the results were shocking so that mask ended up in the landfill
- maybe I will give both adjustments a go tonight and see what happens. Can always try something different the next night , maybe even fixed because I see the 95% last night was pretty much the same as what I had on the PR

Regardless appreciate your input and hope I answered all your questions.

TonyG · Post by **TonyG** » Fri Jan 24, 2020 7:33 am

palerider wrote: ↑
Tue Jan 21, 2020 11:02 am

TonyG wrote: ↑
Tue Jan 21, 2020 8:03 am
. The leak rate shown is double my usual
Yo can't compare the leak rates between Resmed and respironics, the machines report it differently. Respironics shows *total* air that escapes from the mask in any way, Resmed calculates what the baseline vent rate of the mask is, and only shows *excess* leak.

Please review how to format your charts, we don't need mask pressure, but we do need snores and flow limitations. Instructions are in the first post, labeled READ THIS BEFORE POSTING.

I'd actually recommend *raising* the min pressure some, in order to save off the events that are causing pressure to jump, but let's wait a couple days, and see what things look like after you're more used to the new machine.

Here are my last 3 nights. Hopefully these are in order as that is all the info I could display. First night already posted above. On the 2nd night I lowered pressure and EPR by 1 each. The large clusters of centrals at around 3:40 I believe is junk as I think I was awake.The 3rd night I turned EPR off hoping to deal with the centrals further and it seemed to help. The large cluster at the end was junk as I was awake. The 4th night things seemed to go to hell again.

I understand the leak rates are reported differently. However in Encore you could display either total leak or unintentional and the unintentional was always close to what Oscar showed. If you look at last nights leaks , after 6am I was wide awake with my mouth firmly closed and feeling no leak from the mask other then the venting and yet there is leak shown. However my first concern is dealing with the escalated AHI and related events.

I find a big difference with EPR off using the P10 mask vs the P30i which is much easier to breath with. I really would appreciate any suggestions you or anyone else could offer to try and get my settings in order. If I sound frustrated it is because I am . I was thinking about trying my old settings from the PR on fixed pressure to start just to try and get some rest but obviously would like to use the full technology of this new machine if I could. I would really appreciate any advice you or anyone could provide. Thanks.

realshelby · Post by **realshelby** » Fri Jan 24, 2020 7:41 am

Looking at those leak rates, I am thinking you are breathing through your mouth some? P30i leak rates should be more stable than that. Part of the night there is very little leak reported, which tells me you are either dislodging the mask ( fairly hard to do with the P30i ) or mouth breathing when the leak rates jump way up.

Pugsy · Post by **Pugsy** » Fri Jan 24, 2020 8:47 am

TonyG wrote: ↑
Fri Jan 24, 2020 7:33 am
If you look at last nights leaks , after 6am I was wide awake with my mouth firmly closed and feeling no leak from the mask other then the venting and yet there is leak shown.

You are worried about what I call the baseline leak because it isn't at the 0.0 line which we assume it would/should be especially since at the very beginning of the night for about 45 minutes it does seem to be at 0.0 and after around 00.00 things go off tilt a bit and never really settle down.....even after 06.:00 when you know you were awake and not mouth breathing and couldn't detect any excess leak anywhere beyond the venting.
And I see Tues Jan 21 report shows the leak as we would expect it with baseline 0.0.

Is this correct?

I have had this happen from time to time and I can't explain why. Let me think on this a bit after I get more coffee in me. I had a rather rough night last night myself.

As far as last night's ugliness. My best guess is that probably the bulk of the ugly is probably more SWJ related than anything else.
You are used to EPR in some fashion and didn't sleep so great with it turned off. I have been there and done that myself and if you think yours is ugly...you should have seen what happened when I turned off the exhale relief on my Respironics machine some years ago.
I need to find the images if I can and fix the mess photobucket did with them here. After more coffee I will try to fix it. Damn photobucket.
viewtopic.php?f=1&t=67883&p=631376&hili ... mb#p631376

Sometimes when the body is used to something and we take that something away from it....the body throws a foot stomping fit and we just sleep like crap.

I don't think your centrals are related to EPR being used. I think that the slight reduction you got with the reduction in EPR at first was just a coincidence and normal nightly variations.

TonyG · Post by **TonyG** » Fri Jan 24, 2020 9:54 am

Pugsy: Yes Tuesday was a night which would be more in line with my normal recently on the PR1 including leaks. Take away the junk at the end and the results are not too bad for this time of the year. I said this time of the year because it seems like the last 2 years in Dec. and Jan. in particular my AHI numbers jumped for unknown reasons but settled back down after that. From last Mar. through Oct. I was at AHI around 1with minor leaks and feeling pretty good. After the time change in Nov. things came a bit unglued ( AHI still under 2) but not to the extent it is now. I was using fixed pressure at 9.5 with cflex+ at 2. It is pretty frustrating when you have had pretty good success in the past to see crap like I have seen lately. I was a bit concerned switching brands but with all the positive stuff I heard about the Airsense I decided to take the plunge. Hopefully long term I will feel better about my choice.

I am thinking about going back to what I used on Tuesday i.e min 8 epr 1 ( Monday as previously shown was min 9 epr 2, Wed. I turned epr off) or possibly giving fixed a try at my old PR settings with epr 1. I seem to always have trouble when I try APAP. I appear to be very sensitive to changing pressure it seems. I know people frown upon using fixed but I am more about what works best. It would be great if I could dial in APAP but one can only sleep like dog s--- for so long. I'm not a quitter though so hopefully something good can be found.

I really do appreciate people taking their time to try and help a fellow papper in need. Hopefully with your help I can see the light. Thanks again.

Shelby: Yes I do mouth breath some. Use a chin strap which I hate but any attempts to try ffm were disastrous ( leaks were 0 but all else went to hell) but never had leak issues to this extent regardless. Up until a couple years ago I didn't need a strap but a weight gain seemed to change that.

Pugsy · Post by **Pugsy** » Fri Jan 24, 2020 10:19 am

By all means give fixed pressure a try. Some people just seem to feel like they do better with it than with auto adjusting pressures.

I went back through some of my old leak reports. On occasion I have that weird baseline and I haven't changed anything.
I am more inclined to just chalk it up to cpap machine just going weirdo on the calculations to establish whatever it does to report excess leak only. I wouldn't worry about it myself.

TonyG · Post by **TonyG** » Fri Jan 24, 2020 11:01 am

Pugsy :Yeah I think I will give it a try at 9.6 with epr 1 and see what happens. I am pretty tired so want to get some sleep before I play around with APAP anymore. These are the worst results I have ever encountered and are quite surprising. Do you have any good references with regards to trying to understand the effect of epr on therapy? I have seen it said here numerous times it can lead to centrals but not sure why. Would like to better understand the leak situation as well but I will wait until I am settled. That one really puzzles me because leaks to this extent have never been an issue in the past.To make matters worse appears I may have a bit of a head cold coming on so not looking forward to that. I do appreciate your input and if you have any other suggestions I would be all ears. Thanks again.

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