A Question re: my AUTOPAP Trial

I've got a Remstar Auto w/C-flex (this one: https://www.cpap.com/viewImage.php?PNum ... ex_top.jpg) on loan from my doctor's office until Thursday (a one-week trial). The machine is set to run from 7-14 cm. It starts at 7 cm each night, and the pressure when I wake up has been:

Friday morning: 7 cm
Saturday morning: 14 cm
Sunday morning: 14 cm
This morning: 8.5 cm

I used the ramp feature on Thursday night, but it seemed to me it took forever to start ramping upward (if it ever did), so I haven't used the ramp since. I did get into the clinician's menu on Friday to check the settings the office had made, and the machine is set to run on Auto, with a min pressure of 7 and max of 14, but the ramp time was confusing. The options were 4:00, 3:00, or 2:00, and it was set to 2:00. Could that be two hours??? I couldn't seem to change it to something like 20 or 30 minutes, so I left it as it was and just stopped hitting the ramp button at bedtime altogether.

My question is:

Do these different waking pressures indicate that I need an Autopap? Or is there no way to tell, and I just have to wait until the office reads the data card to see what's going on? Impatience is my middle name...

I'm told I can try a Bi-PAP if the Auto doesn't seem to be working well for me. I slept very poorly on Thursday night and struggled mightily all day Friday to stay awake. It felt like the machine was pushing 7 cm all night long, but that's just based on how crummy I felt. It's gotten a little better since then, but I'm yawning all day, every day.

Thanks for any input. I hope to get some answers when I return the machine, but I'd appreciate the knowledge and advice of the experienced users here. Any additional "ammo" I have with which to insist on a better machine than the basic one I was given when I started therapy is a good thing.

I use my APAP in auto mode every night, and my pressure needs vary somewhat every night. I'm an APAP guy, cannot imagine using straight CPAP. But, I know that others prefer straight CPAP. And, I never liked the ramp feature. We're all so different!

That 2:00, 3:00, 4:00 is in fact 2, 3, or 4 hours. In auto mode those are the choices. It will ramp from 0-45 minutes in cpap mode. With a minimum pressure of 7 do you really need the ramp?
I found that the constantly changing pressures of the auto disrupted my sleep and I changed to straight cpap. I do much better with one set pressure.

Brenda

if you have those times, you are doing what is called a split study

on the tank APAP you can't use ramp in Auto mode as Brenda said

if you didn't start with having those 2, 3, and 4 hours in the menu, you better get that fixed as that will screw up what you are using the machine to accomplish (in other words you probably should contact the DME and yell - HELP)

Hi, Rip and bdp.

With my regular CPAP machine (now set at 14), I do use the ramp feature; it starts at 7.5 and runs for 20 minutes. I stopped hitting the ramp button on this APAP loaner after the first night. It starts out at 7, so no need for the ramp. (Speaking of the ramp on this machine, WTH is the point of a two-hour minimum timeframe? That just seems crazy to me.)

When I started the trial period, I was really hoping this machine would make me feel a whole lot better in the morning, since it supposedly is adjusting to suit my needs while sleeping. But I don't feel better; I feel even more tired. I can't wait to see what the data has to say. It'll be interesting to see whether my perception of my poorer sleep quality will be borne out by the numbers.

The sooner I start getting the kind of therapy I really need, the better. I'm a good patient, but I'm seriously frustrated by the lack of cooperation I get from my doctor and my DME. (I know I'm far from being alone here, but it doesn't change anything.)

Anyway, thanks for your comments.

BleepingBeauty wrote: I used the ramp feature on Thursday night, but it seemed to me it took forever to start ramping upward (if it ever did), so I haven't used the ramp since. I did get into the clinician's menu on Friday to check the settings the office had made, and the machine is set to run on Auto, with a min pressure of 7 and max of 14, but the ramp time was confusing. The options were 4:00, 3:00, or 2:00, and it was set to 2:00. Could that be two hours??? I couldn't seem to change it to something like 20 or 30 minutes, so I left it as it was and just stopped hitting the ramp button at bedtime altogether.

If you saw 2:00 as a setting number that was put in for your machine, and you didn't accidentally change it to 2:00 when you went through the clinical menu yourself, my guess is that the DME screwed up when setting your machine for the autopap trial. That is, unless the doctor SPECIFICALLY ordered the DME to set the machine for "Split Time."

That 2:00 that you saw meant the machine uses the minimum pressure of 7 for TWO HOURS at the beginning of each night. After the two hours has expired, then (and only then) will the machine begin operating in "autotitrating" mode for the remainder of the night...varying the pressure as needed. During those two hours, even if your breathing is getting more and more flow limited...heading toward having an apnea, the machine will continue to blow just the pressure of 7 and will not respond in autopap fashion.

No wonder you have had the impression that "ramp" was taking an awfully long time. The Split Time setting of 2:00, 3:00, 4:00 (and "off") is not "ramp." It's a Split night therapy mode setting, and should not have been turned on at all, if what the doctor had ordered was simply a trial on autopap.

If the doctor didn't tell the DME to set the machine that way...for "Split Time"... that setting should have been left at "off."

jules wrote:if you have those times, you are doing what is called a split study

on the tank APAP you can't use ramp in Auto mode as Brenda said

if you didn't start with having those 2, 3, and 4 hours in the menu, you better get that fixed as that will screw up what you are using the machine to accomplish (in other words you probably should contact the DME and yell - HELP)

Hi, Jules. It might be because I'm so tired, but your response confuses me.

My doctor's office set this machine up for me, not the DME. If the ramp feature can't be used in Auto mode, why would they tell me the ramp would start at 7? Can these people really be that inept at their chosen profession? (You don't have to answer that, it's rhetorical.) The screen on the top of this machine tells me nothing but the current pressure; when the machine is off, it shows the number of hours used. I got into the clinician's menu to see how it was set up, but I didn't change anything. The ramp feature said "2:00" and I left it that way. I haven't used the ramp feature since my first night with this machine.

Are you telling me that this machine is NOT set up to auto-adjust to my pressure needs, as was intended? And if that's the case, is this whole week-long trial a total waste of time?

I see RG beat me to it...... But, here's the instructions in case you want to save them. The older Auto settings are different then the newer M Series settings.

Den



REMstar Auto w/C-Flex Setup

When in the Setup Menu, the humidifier ^ and ramp v buttons operate as up and down keys to change the settings, the left/right user buttons < > allow you to go to the previous/next question or setting, and the pressure start/stop button is used to exit the Setup Menu. Holding the humidifier or ramp buttons down will cause the values to change more quickly.

To enter the Therapy Setup Menu, hold the two top user buttons < > down while plugging in the power cord.
Continue holding the buttons down until the REMstar Auto w/C-Flex beeps twice.

Note: The word "setup" will appear on all of the screens indicating that you are in the Therapy Setup Menu.
(If you press the Pressure start/stop button, you will exit the Setup Menu.)

A. Compliance hours/nights: (recommend leaving alone, but CAN be cleared at this point)
Select next setting with >

B. Therapy mode: (CPAP/CFLE/APAP/AFLE) select with ^ or v
Select next setting with >

B1. If CPAP or CFLE select pressure setting: Select with ^ or v
Select next setting with >

B1a. C-Flex mode (if you chose CFLE mode): Select setting 1, 2 or 3 with ^
Select next setting with >

B2. If APAP or AFLE, select minimum pressure setting: Select with ^ or v
Select next setting with >

B2a. If APAP or AFLE, select maximum pressure setting: Select with ^ or v
Select next setting with >

B2b. C-Flex mode (if you chose AFLE mode): Select setting 1, 2 or 3 with ^
Select next setting with >

C: Ramp time setting: Select with ^ or v
(ramp time will be turned off with a setting of 0:00)
(if using APAP or AFLE mode, Ramp setting MUST be set to 0:00)
Select next setting with >

D. Ramp pressure setting: Select with ^ or v (use only in CPAP or CFLE mode)
Select next setting with >

E. Patient disconnect setting: 1 = on 0 = off Select with ^ or v
Select next setting with >

F. Buttons lights setting: 1 = on 0 = off Select with ^ or v

(Last setting. Use On/Off button to exit Setup)

BleepingBeauty wrote:

jules wrote:if you have those times, you are doing what is called a split study

on the tank APAP you can't use ramp in Auto mode as Brenda said

if you didn't start with having those 2, 3, and 4 hours in the menu, you better get that fixed as that will screw up what you are using the machine to accomplish (in other words you probably should contact the DME and yell - HELP)

Hi, Jules. It might be because I'm so tired, but your response confuses me.

My doctor's office set this machine up for me, not the DME. If the ramp feature can't be used in Auto mode, why would they tell me the ramp would start at 7? Can these people really be that inept at their chosen profession? (You don't have to answer that, it's rhetorical.) The screen on the top of this machine tells me nothing but the current pressure; when the machine is off, it shows the number of hours used. I got into the clinician's menu to see how it was set up, but I didn't change anything. The ramp feature said "2:00" and I left it that way. I haven't used the ramp feature since my first night with this machine.

Are you telling me that this machine is NOT set up to auto-adjust to my pressure needs, as was intended? And if that's the case, is this whole week-long trial a total waste of time?

YES!!!

I couldn't resist the opportunity to answer it.

Den

rested gal wrote:If you saw 2:00 as a setting number that was put in for your machine, and you didn't accidentally change it to 2:00 when you went through the clinical menu yourself, my guess is that the DME screwed up when setting your machine for the autopap trial. That is, unless the doctor SPECIFICALLY ordered the DME to set the machine for "Split Time."

That 2:00 that you saw meant the machine uses the minimum pressure of 7 for TWO HOURS at the beginning of each night. After the two hours has expired, then (and only then) will the machine begin operating in "autotitrating" mode for the remainder of the night...varying the pressure as needed. During those two hours, even if your breathing is getting more and more flow limited...heading toward having an apnea, the machine will continue to blow just the pressure of 7 and will not respond in autopap fashion.

No wonder you have had the impression that "ramp" was taking an awfully long time. The Split Time setting of 2:00, 3:00, 4:00 (and "off") is not "ramp." It's a Split night therapy mode setting, and should not have been turned on at all, if what the doctor had ordered was simply a trial on autopap.

If the doctor didn't tell the DME to set the machine that way...for "Split Time"... that setting should have been left at "off."

Thank you, RG, for that explanation. No wonder I'm feeling so crappy!

I guess I've answered my own rhetorical question and can now confirm that yes, the people I rely on at my doctor's office are useless. (They gave me this loaner, not the DME, and there was no mention of this being a split-study. I was told this would be an Autopap trial for a week.) God help me, with these people...

They'll be lucky if I don't start ranting and raving - with plenty of bleeping - when I see them on Thursday to return this machine. I'm so fed up I could scream or cry (or both). Thanks again for the explanation. At least I know my perception isn't far off, and I'm not nuts. Yet.

Wulfman wrote:I see RG beat me to it...... But, here's the instructions in case you want to save them. The older Auto settings are different then the newer M Series settings.

Den

<snip>

Thank you so much, Den. I appreciate you posting those menu instructions.

I'll be relatively dead by Thursday, when I return this machine, with the lousy therapy I'm getting, but I don't want the doctor's office to know I accessed the clinician's menu to see what the settings were, nor do I want them to think I changed anything. So I'll suffer through the next three nights with the settings as-is and will have plenty of ammo with which to INSIST that they let me monitor my own therapy from now on. I've been wanting to take control of this process for over a year, and this screw-up on their part will go a long way towards helping my argument.

It's such a shame that we patients have to be subjected to this kind of professional "help."

BleepingBeauty wrote:My doctor's office set this machine up for me, not the DME. If the ramp feature can't be used in Auto mode, why would they tell me the ramp would start at 7? Can these people really be that inept at their chosen profession? (You don't have to answer that, it's rhetorical.)

Well, yeah, they may be inept. They may be completely unaware of the difference between "split night therapy" and "ramp", and may also be ignorant of the fact that that older model of the REMstar Auto does not even have traditional "ramp" at all when operated in auto mode.

That machine offers "ramp" only when the operating mode is set for straight CPAP. CPAP or CFLE (cpap with C-Flex turned on) as the operating mode. When the machine is set to operate in autotitrating mode (APAP or AFLE..auto with C-Flex turned on) "ramp" cannot be used...ramp is not available at all in either of those "auto" modes. You can push the ramp button during the night, however, if you wake up with a lot of pressure blowing at you and want to make it drop down quickly to the minimum in the range.

In the older machine's auto mode, the setting that "looks like" it might be a ramp setting and appears where, in the menu, you'd come to "ramp" if the machine were in cpap mode, actually has become a setting for split night therapy mode.

In the newer M series machines, some of that confusion was eliminated by the fact that ramp is available in the M series auto, when in auto mode. Just like when in cpap mode. And a separate setting for "Split Time" appears farther on in the menu, clearly using the words "Split Time." But in that older auto, those words aren't used. In the older autopap it can still look like a usual ramp setting to someone setting it up who doesn't know better. The fact that there's no 0 - 45 minutes (the usual range of "ramp" times) available to choose from.... just the 2:00, 3:00, and 4:00 (which are "hours") should give them a clue to dig into the clinical manual to see just what that setting does. Or go ask someone. But the "someone" they ask might not really know either.

Maybe that's the way that doctor wants to do autopap trials... as "Split Night Therapy" trials...but I bet it's not. They may all cover the mistake by saying that's the way they "always" do it there, but I seriously doubt that's what the doctor really intended.

BleepingBeauty wrote:Are you telling me that this machine is NOT set up to auto-adjust to my pressure needs, as was intended?

With the Split Night therapy mode turned on (by being set for 2:00 hours) the machine won't auto-adjust during those first two hours each night. It will blow a straight 7 (the minimum pressure in your range of 7 - 14) during those first two hours, no matter what's happening. It will begin auto-adjusting only after the two hours is up. It will auto-adjust for the rest of that night.

Next night, same thing happens again...no auto-adjusting for first two hours. Auto-adjusting after the two hours is finished. It will do like that every night until that split night therapy setting is turned off by being set for 0:00.

Maybe that's the way that doctor wants to do autopap trials... as "Split Night Therapy" trials...but I bet it's not. They may all cover the mistake by saying that's the way they "always" do it there, but I seriously doubt that's what the doctor really intended.

I think you're right that this was not intentional. Nobody said anything about a "split night therapy" trial; it was simply a week-long trial with an Autopap machine. I understood that it would automatically titrate to whatever pressure I needed at any given time, all night long, within the parameters they set. In fact, when I was picking up the machine last Thursday, I asked what the ramp was set at (since I didn't know that it doesn't have a ramp feature in auto mode). I thought this machine might jump to 14 too quickly without a ramp. (My regular machine is set to start at 7.5 cm with a ramp time of 30 minutes.) They said the machine was set to start at 4 cm, and I said I'd suffocate with that low of a pressure. They then upped it to 7.

Thanks again, RG. You have a way of explaining these things that make it easy for my sleepy brain to grasp. May I ask: If my doctor did intend to do a "split night" autopap trial on me, what would be the point of it? I've had four in-lab sleep studies done over the past 17 months, since this adventure began. I don't understand what the first two hours at 7 cm would glean in the way of information that would be useful, at this point. Is there something here that I'm missing?

TIA

BleepingBeauty wrote: If my doctor did intend to do a "split night" autopap trial on me, what would be the point of it? I've had four in-lab sleep studies done over the past 17 months, since this adventure began. I don't understand what the first two hours at 7 cm would glean in the way of information that would be useful, at this point. Is there something here that I'm missing?

As I understand it, the whole reason for deliberately doing a split night test with an autopap would be to get a look (for several hours) at how many events were happening without effective "treatment pressure"; then let the machine auto-titrate for the remainder of the night to see what pressure (the 90% pressure) prevented most events from happening. Having the minimum pressure at 7 is definitely delivering quite a bit of possible effective treatment pressure, so would not be the way to conduct a meaningful "split night therapy" test at all, imho.

I think the person who set up the machine for your autotitration trial goofed.

If you review the hypnograms that BB posted in the other thread, you will note that there are essentially no events on low-level PAP (events are color-coded in that software and the lighter ones don't show up that well, but I don't think there are any at <10 cmH2O).

BB also purports to have central disturbance (which is debatable, but put that aside for a minute) which may be pressure-generated in nature. With not much time studied on low level PAP, which is essentially event-free, and too much time on higher pressures, which is chock-full of events, many apparently central in nature, getting more data on low level PAP could be very helpful. Locking that thing at low-level PAP for a couple of hours could be a good idea, since I don't believe there's any guarantee that it will correctly identify NR (central) apneas and stay at low level in straight APAP mode.

While that may or may not have been the rationale of whoever is wingin' those dials, I think any information has the potential of being helpful information.

SAG