Recommendations

Hello Everyone,

I have been recently diagnosed with mild/moderate apnea, and was prescribed a remstar auto M series cpap and used it for a few weeks. However it kept revving up and blowing at me even before i was asleep. They changed it for a system one auto a-flex, which i have used for the last 10 days. Definately more tolerable. Settings are 4 to 16 cmH2O + auto.

I have started looking at the waveform data and see some Cheyne-stokes and other stuff going on (see below). Hopefully soon i shall go back to the sleep doc, and would be interested to hear any recommendations, and topics to bring to his attention. AHI is around 9.
The mask is quite uncomfortable so i have ordered some Remzzzs to try and pad it.

Congrats on an informative forum.

SleepyJohn, welcome to the forum. There are many here who are FAR more knowledgeable than I, but here are a few thoughts. In the U S it is my understanding that the DME companies who provide the masks are supposed to give you 30 days to try out a mask. I was not told this by my supplier and it would have helped me a lot. I think that mask comfort is probably more than half the battle and it irks me that suppliers do not encourage new patients to try different styles. So if I were you I would really check out the possibility of changing the mask. Another place to look for liners etc to increase your comfort is padacheek.com. I dont know what the possibilities are for international shipping but the products there are all designed to really help you live with your chosen mask in as comfortable a way as possible. There have been many threads on this forum about Remzzz and padacheek etc so it might be worth searching through them for ideas and feedback. I have no doubt that you will get valuable responses concerning your graphs here. that subject is out of my range!!

Thanks Bayourest i will check out your suggestions.

As to my graphs - should i return to my home planet, or are there others here like me

Boy these Resmeds give a plethora of data that Respironics do not. Looks to my very inexpert eyes like you are having hyponeas. If your sleep study did not mention centrals (I would guess not or you would have a different machine) then maybe you are still obstructing. Hopefully SWS or one of the gurus will see this and give an opinion.

Are these typical of your entire night, or are these hand-picked as unusual? You're on the right planet to learn more. Welcome.

That's not a ResScan graph, that is an EncorePro Wave Form graph. Central apneas are NOT necessarily Cheyne-Stokes breathing. Or are you talking about the "periodic breathing". We all occasionally do some of both, or at least most of us, even "normal" non-apnean folks do on occasion.

I know the graph isn't showing high leak but I'm wondering if reducing the pressure range wouldn't also reduce those OAs and PBs as well as improve your sleep. 4-16 is a pretty wide gap! I'd be inclined to reduce that gap somewhat. Your breathing lines are way off the red line. I interpret that (I could be wrong) to a need to increase that bottom pressure 4 to MAYBE 6, at least to 5, and work my way up from there if necessary.

I'm only a patient, not a sleep professional.

Thanks for your responses, and quick too!

DreamDiver - these episodes happen a few times a night, but i also get a couple of hours steady breathing.

Slinky - The software marks what it interprets as C-S respiration in green. I seem to have that a couple of times a night, as well as a few episodes like the other waveforms show. The sleep lab test used a portable unit that i strapped to my arm at home and then brought back to them, there was no real information given to me except a diagnosis of mild/moderate apnea. As it was all new to me i didn't do much asking, but was relieved to get the machine. I have since realised that i have centrals and periods of very shallow breathing during waking as well, and have done for years, usually while concentrating!
The pressure certainly wakes me when it ramps up, and i pull off the mask or shut off the machine at that stage, at around the 11 or 12 mark. Its ok again when i start it back up.

SleepyJohn wrote:... The software marks what it interprets as C-S respiration in green.

Technically, it's period breathing that's being highlighted in green, of which Cheynes Stokes is a very extreme form. We're not seeing periodicity for hours on end, where there is an obstruction every few minutes like clockwork, from what you're telling us. If most of your sleep is relatively-steady breathing studded with small windows of mild periodic breathing that sounds a lot like what happens with many of us. I agree with Slinky in that your pressure range is probably too wide. If you're just a few days in to using the machine, it would be nice to know some things for the night of this graph and in general:
AHI
Pressure settings for your machine as prescribed by your sleep doc
Pressure settings now if you have changed them
What led you to your decision to change settings
Maximum Pressure reached for the night
90th percentile pressure for the night.
How many nights have you used the machine so far
What's your average AHI for the total nights you've used it so far.

DreamDiver - thanks for taking the time to respond and look at my details. It is reassuring to get advice from someone with experience.

AHI was 9.9
Prescription is 4cm min, 16 max
I havent changed any settings, nor shall i until doc prescribes, or i have a much better understanding of what is going on. Am in learning mode.
That said, the first M series machine would start blowing even when awake (Tech saw this and so issued me with the System One). Pressure levels were the same on the first machine. This new machine wakes me up when the pressure goes high, see image below, which is why i would like to find a more comfortable setting:

90% pressure was 9.9
I have used the new machine for 10 nights, and the old for about a month before that. Sleep has fragmented to about 2 or 3 hour slots, however my breathing feels "fresher" if that makes any sense. I have kept the nurse informed - she sent the tech who then changed the machine.
Average AHI is 7.9

Sorry to be terse, i am just a little tired, heading for the nest soon, and thanks again.

Others may have different, more knowledgeable opinions. I am not a doctor. However, this is what I get from your data.

If you're starting at 4, that means your body is still having apneas until it gets to a higher pressure, but seems to spend a lot of time around 10cm H20, or just under. That's the 90% pressure (9.9). Not surprisingly, that is pretty close to the minimum pressure setting for many forum members. I'm curious if you had an actual titration or if you were just sent home with a machine to get used to it before the sleep lab titration. That's the only time I can imagine a doctor would give you such a wide range of pressure on an auto. Many people find themselves unable to breathe at 4cm. Again, there are examplary forum members who cannot tolerate much more than 6 without aerophagia, so I know it's different for everyone, but for me, 4cm pressure would just about stifle me. I'd be ripping the mask off. I can barely stand the pressure to be as low as 7cm.

If these were my settings, I'd raise the minimum pressure. When the pressure is so high that it wakes you up, are you getting aerophagia (air forcing itself into your esophagus), or is it because you can't easily breathe out? In either case, I'd suspect that max pressure setting is too high. If it's the abrupt change in pressure that was waking me up and not aerophagia or inability to breathe out, then I'd consider the possibility again that narrowing the range between min pressure and max pressure might reduce sleep arousals.

It makes sense to talk with your doctor if you're not comfortable making changes. If you haven't yet been titrated, I'll bet they'll be using this data to start you somewhere around 7 or 8 for the minimum and go as high as 11 or 12 during the night. I wonder if they'll suggest straight CPAP at around 10cm when your all titrated. From there, it'll be a case of tightening, loosening or shifting the pressure range to better suit your needs as you get more used to using the machine. An AHI of 7 or 8 within the first couple weeks is a good start. It's better than mine was for the first two weeks. You'll get it lower as your body gets used to it and as you and your doctor get a handle on things.

Why not post that Summary of Daily Events Per Hour table for us?

And, DreamDiver, do YOU know what the black dots in the red line are? I haven't found any one yet who does, but we've been speculating maybe they are pressure changes?????

Slinky wrote:Why not post that Summary of Daily Events Per Hour table for us?

And, DreamDiver, do YOU know what the black dots in the red line are? I haven't found any one yet who does, but we've been speculating maybe they are pressure changes?????

I simply assumed as you did that they mark the beginning and ending of each incline or level line with regards to pressure. For very long or narrow inclines, it's easier to discern about when in time the rise or fall begins or ends when they are punctuated like that, since PDF's are the only method of graph discovery for Encore Pro.

Slinky - Here is the table of daily events:



The lowest AHI is at 12. Does that mean 12 would be optimal, or is it low because i havent spent so much time at that pressure?

DreamDiver - you are correct in thinking I never had any titration. The tech brought the machine and just set it up, presumably to the script that the sleep doc had written. Nothing more was said except see you in 3 months!
Pressure blowing the mask off my face and releasing air into my eyes is what wakes me. I cant say that i have had difficulty breathing at that pressure, I think its mainly the noise. Its like waking up with your head stuck out of the car window!

Have you tried JediMark's Sleepyhead application? It is excellent running in Ubuntu and allows you to zoom in the waveform to small timeperiods, i havent yet tried the windows version. EncorePro waveform output seems to be only .pdf. Is the raw waveform available in any other format in Encore?

Good Sleeping everyone

SleepyJohn wrote:Slinky - Here is the table of daily events:



The lowest AHI is at 12. Does that mean 12 would be optimal, or is it low because i havent spent so much time at that pressure?

DreamDiver - you are correct in thinking I never had any titration. The tech brought the machine and just set it up, presumably to the script that the sleep doc had written. Nothing more was said except see you in 3 months!
Pressure blowing the mask off my face and releasing air into my eyes is what wakes me. I cant say that i have had difficulty breathing at that pressure, I think its mainly the noise. Its like waking up with your head stuck out of the car window!

Have you tried JediMark's Sleepyhead application? It is excellent running in Ubuntu and allows you to zoom in the waveform to small timeperiods, i havent yet tried the windows version. EncorePro waveform output seems to be only .pdf. Is the raw waveform available in any other format in Encore?

Good Sleeping everyone

I believe my predictions about what your doctor might say are premature after seeing this new data. Your AHI is lower at pressure of 6, and you've spent a goodly bit of time at there. Your body is still new to this, so with time, it may be that these data are suggesting you might do well at that pressure. And yet your machine keeps taking you higher, and you've spent almost as much time at higher pressures with another dip in AHI at 9.You're never getting to 16, and you keep waking before 14 cm, so your maximum for range could definitely be lowered... Fascinating. I'd like to see what Slinky's thoughts are at this point.

A prescription pressure range of 4 to 16 cm is almost always nonsense and of course not effective. You can see from the way the pressure is violently climbing during the night that the minimum is set much too low.

If it were me, I would immediately change the minimum pressure to 10 cm and leave the max at 16. Then check the daily details the next morning and see if the events have been reduced. I don't believe in suffering with the wrong pressure for weeks or even one week.

You also need to post the graph of your leak line.

What was your diagnosis? AHI? Central apneas? Oxygen desaturations? Any comorbidities?

Did you have a titration study? What was the single pressure that best treated your breathing?

With settings of 4 to 16, I suspect you did not have an in-lab titration study and the doc is going to use the data being collected now to set a final narrow range of pressure. Is this the intention? You need to know this. Otherwise a setting of 4 to 16 would only make sense for someone whose apnea was controlled by a pressure of around 4 to 7 cm.