I need Help Understanding how a ResMed VPAP Auto 25 Works

She does leak from her mouth from time to time. We got her a chin strap. When she wears the chin strap the leak line looks real good .... just an occasional spike problaby when she's rolloing over .... other than that low and fairly flat. BUT .... the chin strap is another thing that she has a hard time keeping on.

This whole thing has been a battle. If I could only get it to the point that she was comfortable with it enough to wear it though the night I would just up and down yelling hooray.

First thing we need to do is get the "burning sensation" in her nostril resolved. We're gonna kick it up in high gear this week and push HARD for a solution. We've tried a bunch of masks .... maybe time to try some more .... PLUS I want to talk about the pressure settings and see what can be done with them. Since I have never seen the machine hit the top, that one is probably OK ..... AND if the machine should adjust pressure upwards towards the top when needed, maybe we can get the Min EPAP lowered a bunch ..... as long as the machine still provides enough air to breath I don't see why we can't lower the Min EPAP to a number that will provide her comfort for the long hall.

I'm also looking at different chinstraps ......

Thanks for you help Jeff .... and everyone else too .... it is truely appreciated.

Fred

Just thought of another question ..... her sleep study showed CSA and not OSA ..... does that mean that the machine might be used dfferently since it's not an obstruction?

Oooooooopsie!!!! THAT is an important clue!!! Her sleep study revealed CSA and NOT OSA????

I'll let others more experienced and knowledgeable jump in on this one - BUT - CSA instead of OSA is a REALLY IMPORTANT difference!!! It sheds a whole new light on a whole new ball game!!!

fredn wrote:..... her sleep study showed CSA and not OSA .....

Would you mind clarifying that, Fred?

(1) Are you saying that the doctor's diagnosis, written specifically on the sleep study, is that your wive HAS central sleep apnea, in the sense of being diagnosed with it, and that is what the machine was prescribed to treat?

OR:

(2) Are you saying that the sleep study recorded a few central apneas, but that, according to the doctor's written diagnosis, she was diagnosed with OSA (perhaps because of the large number of hypopneas that occurred during the study leading to an OSA diagnosis)?

Those are two VERY different situations, as I understand it, although I can see a patient describing both situations similarly as the "sleep study showed CSA."

Having a few centrals during a sleep study is NOT the same as being diagnosed with the condition "central sleep apnea."

Which is the actual situation--number one, or number two?

Jeff,

I believe it is case number 2 ...

All I have to go on it the report from the sleep study ..... we are going to be asking some more questions this week ... for sure.

Here's what the Sleep Study says in the section titled:

Respiratory Statistics: Respiratory Events

Numbers
------------------------------------------------------------------------------------------------------
Apnea + Hypopnea (A+H): 41
Apena: 3
Obstructive Apenea: 0
Central Apnea: 3
Mixed Apnea: 0
Hypopnea: 38


Numbers in REM
------------------------------------------------------------------------------------------------------
Apnea + Hypopnea (A+H): 40
Apena: 3
Obstructive Apenea: 0
Central Apnea: 3
Mixed Apnea: 0
Hypopnea: 37


Numbers in NREM
------------------------------------------------------------------------------------------------------
Apnea + Hypopnea (A+H): 1
Apena: 0
Obstructive Apenea: 0
Central Apnea: 0
Mixed Apnea: 0
Hypopnea: 37

The wording for the diagnosis was this: Based on this study there was evidence of MILD OSAS with an overall AHI of 7 (Normal: 5 or less) and oxygen desaturation. The lowest oxygen saturation was 83%. The REFRA index was 8. Snoring was moderate. The desease was worse during REM sleep with an AHI of 27, which falls in the "moderate" category. There is some more but that is the jist of it.
Fred

BTT

Thanks for posting that, Fred. That should put people's mind at ease (including mine) who were afraid she had central sleep apnea as a diagnosis.

I am very surprised her machine isn't recording any hypopneas. It is my understanding that a ResMed S8 (or S8 II) tends to record hypopneas even with people with no disease. So I find that odd, myself. I wonder how low the pressure would need to go for her to start having home-machine recorded hypopneas?

I am very curious to find out what the Rx was. I wonder if the machine was set up differently from what the doc prescribed? I look forward to hearing what is written on the actual Rx.

Jeff,

Her machines does show hypopsneas ..... below is a typical night



I've been doing some more reading today .... I'm reading that her Machine (ResMed VPAP Auto 25) DOES NOT increase pressure for a hypopnea ... nor would it increase pressure if she were to have a CSA (not being an obstruction) ..... PLUS I believe it only increases pressure for an Apnea that goes longer than a specific duration in time ....... so basically her machine would just about never increase in presure .... or so it would seem.

So basically this thing just provides the pressure (MIN EPAP + Pressure Support ...... which was set up as 11 + 4 = 15) constantly and would never increase .... which is what I DO see going back over all of her detailed graphs .... so it would seem to me that maybe there is a better suited machine? OR maybe the pressure could be lowered until she maintains the proper oxygen level (remember it went to 83% during her sleep study) ......

What ja think?
Fred

fredn wrote: Her machines does show hypopsneas .....

That is nothing for a ResMed S8 series, though. Practically nothing, anyway.

fredn wrote:I've been doing some more reading today .... I'm reading that her Machine (ResMed VPAP Auto 25) DOES NOT increase pressure for a hypopnea ... nor would it increase pressure if she were to have a CSA (not being an obstruction) ..... PLUS I believe it only increases pressure for an Apnea that goes longer than a specific duration in time ....... so basically her machine would just about never increase in presure .... or so it would seem.

ResMeds pride themselves in reacting to indications of obstruction. That machine does not consider one of its scored hypopneas to be an indication of obstruction on its own--it has to see some indication that the change in breathing is obstructive, so it would react to that, not the hypopnea itself. It also assumes any apnea that occurs above a certain pressure is likely central and worthy of being ignored. That is the feature, not a bug.

fredn wrote:So basically this thing just provides the pressure (MIN EPAP + Pressure Support ...... which was set up as 11 + 4 = 15) constantly and would never increase .... which is what I DO see going back over all of her detailed graphs .... so it would seem to me that maybe there is a better suited machine? OR maybe the pressure could be lowered until she maintains the proper oxygen level (remember it went to 83% during her sleep study) ......

What ja think?
Fred

It looks like her OSA is mild, and that at the pressures that the machine is running at, it isn't seeing any indications of obstruction to react to.

I still can't figure out how you ended up with an autobilevel. Maybe the doc felt that he was really going to be treating UARS and hoped a bilevel at high pressure would do the trick. (That is a valid school of thought, according to some, but often includes titrating a larger PS, I think.) I don't know much about that stuff. But there is enough that is unique with what you are saying that I assume either the machine was set up wrong OR the doc had a specific approach in mind other than what is usually done for OSA. He might tend to keep his thinking to himself in that circumstance to cover his butt and to make sure your insurance covers the cost of the machine. But all that is me thinking out loud more than anything. I don't have enough facts to have much of use to say specifically.

I hope you get answers from your team that make sense eventually.

I commend you again for researching to see what to do to make sure she is comfortable, since she was/is having trouble with that. Too many give up without trouble-shooting. I am glad you are on the case, and hope things fall into place for her sooner rather than later.

Jeff,

To be frankly honest .... I think we could have a better Doctor and Machine Provider.

I see that you are in Brooklyn, New York. We are approx 90 miles north of you straight up the Hudson River.

Do you know of any Top Notch Apnea/Hypopnea Specializing Doctors up this way? And/or I guess a top notch Tech?

My wife is going to make some calls today .... as am I, but when we were talking yesterday I told her that my concern is that from the little that I have learned on my own already that I know more about how the machine works than her Doctor or Technician know. When she went into see her Doctor approx 6 weeks after starting treatment, AND complaining about her discomfort I think they changed the machine from "Mode CPAP" to "Mode VAUTO" ..... BUT it was done without ever even looking at "DETAILED GRAPHS" (only summaries) and no follow up was ever done.

The last time she complained to her Tech about the burning in her nose she was told "it's the pressure, there is nothing we can do about it"

I would just love to connect with a Doctor/Tech Team that WANTS TO SOLVE THE PROBLEM .... or at least does something to try.

Maybe "the wheel" hasn't been sqeaking loud enough .... that is about to end. Now that she's out of AFIB the last thing we want to happen is that she goes back in because her Blood/Oxygen levels drops low and it goes back in. (IF HER OSA IS EVEN BAD ENOUGH TO BE A CAUSE)

Fred

fredn wrote:Jeff,

To be frankly honest .... I think we could have a better Doctor and Machine Provider.

I see that you are in Brooklyn, New York. We are approx 90 miles north of you straight up the Hudson River.

Do you know of any Top Notch Apnea/Hypopnea Specializing Doctors up this way? And/or I guess a top notch Tech?

My wife is going to make some calls today .... as am I, but when we were talking yesterday I told her that my concern is that from the little that I have learned on my own already that I know more about how the machine works than her Doctor or Technician know. When she went into see her Doctor approx 6 weeks after starting treatment, AND complaining about her discomfort I think they changed the machine from "Mode CPAP" to "Mode VAUTO" ..... BUT it was done without ever even looking at "DETAILED GRAPHS" (only summaries) and no follow up was ever done.

The last time she complained to her Tech about the burning in her nose she was told "it's the pressure, there is nothing we can do about it"

I would just love to connect with a Doctor/Tech Team that WANTS TO SOLVE THE PROBLEM .... or at least does something to try.

Maybe "the wheel" hasn't been sqeaking loud enough .... that is about to end. Now that she's out of AFIB the last thing we want to happen is that she goes back in because her Blood/Oxygen levels drops low and it goes back in. (IF HER OSA IS EVEN BAD ENOUGH TO BE A CAUSE)

Fred

If the problem is mild OSA, then your doc did his job by diagnosing it. That's often about all they can do--they leave the machine stuff to the respiratory therapists (RTs).

The RTs are often afraid to do much beyond trying to set a machine up as the doc prescribed.

The patient gets caught in the middle.

If you have a diagnosis of mild OSA and a machine (a good one at that), you may be better off learning to customize therapy for yourselves instead of depending on the professionals to do it for you, IF your sleep doc is OK with that. Ask him if there is any reason you should not be customizing therapy for comfort, as in: "Is there anything we need to be careful about?" Then go for the lowest pressures possible for comfort and the lowest AHI with the trending data. Then adjust for feeling the best. Even if there is a UARS element, you will likely do better trying things for yourselves over time to improve sleep quality.

What I'm trying to say is that you work with a team for safety reasons and for anything that involves disease that can be impacted negatively by upper airway pressure. But when it comes to getting therapy comfortable and tweaking for the best sleep, that usually falls to us patients to do for ourselves.

I have friends who have seen docs up there and dealt with DMEs up there, but none of those DMEs or docs are experts at making therapy comfortable and tweaking for the best sleep, even though they are very good at what they do--make a diagnosis and set up a machine according to the Rx.

I think you have the tools and you are getting the know-how. No matter how good the docs or RTs, the bottom line is that none of them love your wife as much as you do. And if you keep posting to this site, you may find more valuable input from fellow patients on what they have found to make their therapy the best and the most comfortable it can be.

Patients use the machines. Docs and RTs often don't. So who are you gonna ask for tips on making the prescribed therapy work? I say patients.

Thanks Jeff .....

I'm OK with making adjustments and watching for results .... I guess my fear is making an adjustment that could do her harm rather than good .... like not getting enough air .... I don't know enough about these machines to know either way.

I'm looking at Info on her machine ... and I see descriptions for the modes that it can be set for ....

CPAP Mode
VAuto Mode .... this is what it is set to now
S (Spontaneous) Mode
S/T (Spontaneous/Timed) Mode
T (Timed) mode

So I'm at the point of not even knowing what Mode to start with ..... escpecially since you wondered about "why bi-level"?

I shall read .... and make some phone calls

Fred

The Auto 25 doesn't have any T modes (T or S/T).

Is that the machine you will be keeping, or are they just having you use a loaner until they figure out which machine you need?

It is true that the professionals have no idea someone is having trouble unless the person speaks up about it. The professionals can help, but finding a way to make the therapy comfortable generally falls to us. Another personal motto on the matter: Safety first; treatment second; comfort third; all on the road to good sleep. PAP is an instant miraculous fix for some people. But for many of us it is a journey that takes some time. Sometimes some small little thing is the key to finally using it all night every night, and that is when the benefit starts to show--after weeks of full compliance. And if there are still problems after that, there are other things to try. So half the battle is just not giving up, in that situation.

jnk wrote:The Auto 25 doesn't have any T modes (T or S/T).

Ha ... I saw that after I posted and re-read the Manual

jnk wrote:Is that the machine you will be keeping, or are they just having you use a loaner until they figure out which machine you need?).

I think they already went ahead and purchased it .... BUT ... I'm not going to let that stand between us and the correct machine

jnk wrote:It is true that the professionals have no idea someone is having trouble unless the person speaks up about it. The professionals can help, but finding a way to make the therapy comfortable generally falls to us. Another personal motto on the matter: Safety first; treatment second; comfort third; all on the road to good sleep. PAP is an instant miraculous fix for some people. But for many of us it is a journey that takes some time. Sometimes some small little thing is the key to finally using it all night every night, and that is when the benefit starts to show--after weeks of full compliance. And if there are still problems after that, there are other things to try. So half the battle is just not giving up, in that situation.

I just got off the phone with our contact at the place that supplies her equipment .... I guess that's the DME? I guess I ought to get the terms right huh? Long conversation .... feel a little better about what she knows as I asked questions ... one thing she did say is that now that my wife is back into normal sinus rthythm she should have another titration. She believes that the pressure prescribed may have had to do with the fact that she was in AFIB and not because of anything hypopnea/apnea related. And MAYBE we would be able to drop her pressure significantly ....

Going to get one scheduled ASAP

Fred

fredn wrote:

jnk wrote:The Auto 25 doesn't have any T modes (T or S/T).

Ha ... I saw that after I posted and re-read the Manual

jnk wrote:Is that the machine you will be keeping, or are they just having you use a loaner until they figure out which machine you need?).

I think they already went ahead and purchased it .... BUT ... I'm not going to let that stand between us and the correct machine

Unless she is diagnosed with something beyond mild OSA, I don't know how you could do better than that machine. I think they have been very generous and helpful with that machine choice for her. Just my opinion.

fredn wrote:

jnk wrote:It is true that the professionals have no idea someone is having trouble unless the person speaks up about it. The professionals can help, but finding a way to make the therapy comfortable generally falls to us. Another personal motto on the matter: Safety first; treatment second; comfort third; all on the road to good sleep. PAP is an instant miraculous fix for some people. But for many of us it is a journey that takes some time. Sometimes some small little thing is the key to finally using it all night every night, and that is when the benefit starts to show--after weeks of full compliance. And if there are still problems after that, there are other things to try. So half the battle is just not giving up, in that situation.

I just got off the phone with our contact at the place that supplies her equipment .... I guess that's the DME? I guess I ought to get the terms right huh? Long conversation .... feel a little better about what she knows as I asked questions ... one thing she did say is that now that my wife is back into normal sinus rthythm she should have another titration. She believes that the pressure prescribed may have had to do with the fact that she was in AFIB and not because of anything hypopnea/apnea related. And MAYBE we would be able to drop her pressure significantly ....

Going to get one scheduled ASAP

Fred

That's great! There may be reasons for another study, related to the afib. However, if the point is to find a pressure to treat the mild OSA alone, I have a feeling you could probably do a fine job finding the right pressures for that using the trending data from the machine itself. There may be insurance reasons for having another study, too. But if not, and a titration has already established there are no sleep problems beyond mild OSA and that she reacts well to pressure (as proved during a titration), your doc may be cool with letting you find the right pressure now that circumstances have changed. I would let my doc know I was willing in that circumstance to home titrate, but I would cooperate with him and insurance if they wanted to do another titration. But hey, that's just my approach, going by the few facts I've heard. Others here might have a completely different approach in your situation.

Meantime, be sure to keep your docs in the loop about any ideas for pressure changes, especially if they have in mind treating something beyond mild OSA. Keeping the pressure somewhere that allows her to use it all night every night as she sleeps is likely as important to the doc as having the right pressure, but anything cardiac is worth keeping a doc in the loop about, right? And not just the DME or the RT, but THE DOC. I would want a green light from the doc that all I was home-titrating for was titrating away mild OSA.

My wife took the night off last night from her CPAP ... she couldn't take her nose burning another night. She put her lanolin ointment on it all day yesterday and when she went to bed last night. She actually slept pretty good ....

Tonight we go to Plan B .... I dropped the Min EPAP down to 6.0 .... Max IPAP is at 16.0 and the Pressure Support is at 4.0 (that's where they both were)

That should put her "operating pressure" at 10.0 .... not 15.0 where it has been. She ought to feel that reduction pretty noticably. She replaced her nasal pillows last night too ... so we'll see tonight. I'll dump the card tomorrow and take a look.

We also working on her getting another "sleep study" and "titration" now that she's back in normal sinus rhythm. I spoke to her cardiologists assistant yesterday ... he's going to prescribe the new studies for us and we'll go from there.

Fred