What is the REMStar Auto really doing?

Thanxs. I finally wandered my way to the export as pdf file which went into my docs folder. Then attached as e-mail. Wait till u see my graphs. geez.

Hi everybody,
Loonlvr has asked me to post the following chart for comments:

I'll leave it to him to expand and raise questions...

derek

Well, its pretty wild for sure. Some nites I seem to have a cluster of OA s like you see. Maybe I should raise my lower pressure. But my ahi is usually over 9 for sure.

Loonlvr, yours is a challenging overnight chart and you should really be consulting a medical professional about your results. There's absolutely no question in my mind about that. Please get a well-qualified medical professional in the loop with respect to fine tuning your PAP therapy if you aren't currently doing that.

Specifically what I am concerned about are those three NR tick marks that hover directly above your nearly-contiguous cluster of OA events. What I think is happening: those non-responsive (NR) apneas are causing your Remstar Auto to refrain from treating that cluster of obstructive apneas. Here is the Respironics representative's description of how the RemStar Auto algorithmically handles non-responsive apneas (see cpaptalk.com review section for entire interview text):

"The REMstar Auto algorithm looks for apnea’s that are non-responsive to treatment which could indicate that these are central events. At any pressure 8 cm H2O or higher we will make three pressure increases in response to a sustained string of events. If there is no improvement after the third increase, indicated by the persistence of events, the pressure is dropped 2 cm and a constant pressure is held for several minutes. If there is snoring noted during this period of constant pressure, which would indicate obstruction, we will increase pressure and reset the non-responsive treatment, thus allowing for three more pressure increases."

Essentially, you experienced a non-responsive (NR) apnea, which very well may be a central apnea. Your RemStar Auto then elected to drop 2 cm and refrain from treating subsequent events for a while according to the above NR treatment criteria. When the RemStar was finally ready to treat you after that first NR, you then experienced yet a second NR event causing the RemStar to drop 2 cm and "sit out" from administering treatment yet a while longer. Eventually the RemStar was ready to treat your obstructive apneas once again and that third NR event caused the Remstar to drop 2 cm and refrain from treating your obstructive apneas yet again. The result is that looooooong succession of unchallenged apneas (some/many of which may have been central apneas). You just may have a recurring central apnea issue during your pressure therapy that hinders your obstructive apnea treatment, and your sleep doctor needs to be apprised of your Remstar's response to your sleep events----and your response to the Remstar's therapy----both reflected in your Encore Pro data.

You currently use a 6 cm to 15 cm pressure range (even though your max pressure is set higher than 15 cm). Additionally, you just might have "fast and heavy" apneic obstructions that require you to narrow your pressure range down to a 6, 5, or even 4 cm spread. I would personally think 10 cm min to 15 cm max would be a great experiment with your doctor in the loop. Please make it a point to get with your health care professionals on this one.

-SWS,

I agree Loonlvr should show this charts to a qualified sleep specialist. In the interim, could he set his auto to a fixed pressure at 12 or 12.5cm (based on his 90% number) and see if that brings his AHI to an acceptable level. If he is having mixed apneas will this potentialy cause centrals? We get a lot of critcism here for encouraging tweaking of our machines but I want to go on the record as stating that I do not support trying to solve issue on your own when the are beyond tweaking therapy that is within the acceptable range of AHIs.

Thanx for the suggestions. Before I go see my sleep guy, I am going to try both your ideas. First, to narrow the range, say 9-16 for a few nites. Then I will set it at a straight pressure of 11, my orginal setting of my first machine. Remember, this is the guy who refused me an auto, so I want some type info to show him. I know he won t be to pleased I went to my reg doc to get the auto. But I am king of my kingdim.

I bet even a health professional wouldn't know how to interpret the Auto's response to loonlvr's chart. I'm certainly not a doctor. but is apparent to me that the Auto is not responding appropriately. -SWS I think your comments on the NR events are spot on. It looks as if they are dominating the overall response - in the middle of a serious apnea attack.

Good people - I have edited this post because I think some of my comments could have done "the cause" more harm than good.

derek

Well another possibility is that he is having an obstruction that is not only non- responsive, but can not be resolved with cpap. (Vocal Cord Disfunction, sleeping on the hose and crushing it?) You might want to set it like Derek said, but I would set the high and low for the same.

What kind of mask are you using?

I m using the ultra mirage full face. Can t use the nasal. I do loop the hose over a pole lamp so that it hangs down to avoid crushing hose(a suggestion from rest gal I think) This nite was rather wild. If derek doesn t mind, I would e-mail him a nite that a little more mellow, but with a still high ahi. around 9-10.

Not to take the position of defender of Repironics, but my guess is that if loonlvr has many central apneas mixed with obstructive apneas that they would claim an APAP should not have been prescribed. Recall that the official Respironics current position on APAP is that it is intended to be used only as a temporary diagnostic tool. Beyond that the CPAP is the "Gold Standard" and failing that a BiPAP is to be prescribed.

I do agree with derek that more info would be helpful in understanding exactly what and what not the auto can do for us.

-SWS, kudos on picking out the key details of loonlvr's data.

My understanding is that central apneas are when the brain doesn t tell the body to breath while sleeping. Is this correct? If it is, whats the solution? I know this is a dumb question but whats the differnce between a bi pap and an auto?

Loonlvr has asked me to post the following chart, which he says is more typical of his nightly details:

derek

loonlvr,

Your understanding of central apneas is correct. Because they are not obstructive in nature (meaning your airway does not close) there is no way for the air splint of cpap to affect them. I'm no expert, but my unerstanding is that central apneas are generaly treated with meds. My understanding is that generaly people with both OAs and CAs a placed on Bipap therapy. A biPAP is different than an APAP or CPAP in that it has two pressure settings. One for inhalation and another lower one for exhalation. My guess is in regard to dealing with central apneas, that the pressure differential of the BiPAP serves to keep the repiratory cycle going, thus coaxing the brain to keep sending signals to breathe. For the most part though in regard to central apneas and xpap therapy, the goal is to avoid causing clusters of central apneas which is why the machine is holding off therapy on the signal of NR events.

Loonnlvr, I do like Wader's and Mikesus' idea about running at fixed pressure. Specifically I would suggest running at the fixed pressure that was prescribed to you after your PSG titration study. I would suggest collecting data at your prescribed fixed pressure as a baseline that you can show your doctor before considering treatment by the AutoPAP's algorithm.

Your second overnight chart shows the same NR-driven problem to a lesser degree. Your NR tick mark is hiding on the dotted line demarcating the 5 hour point in your sleep session. The apneas commence to the left of that line, pressure is progressively increased until the algorithm reaches it's NR recognition point, the pressure is dropped 2 cm, the RemStar "sits out" from subsequent pressure increases for a while, and many apneas (central and/or obstructive) go unchallenged. If you somehow magically eliminated those unchallenged apneas during that single night, your AHI would have been much better.

Would you mind telling us about the results of your PSG titration ?

My number was i believe in the 70s. My fixed pressure was set at 11.