The more I try, the worse it gets.

Pugsy, readings stayed around the same so lowering the ip didn;t effect anything but I think I did deal with the aerophagia better. I think as long as my ip can go up to 12 or 13(and with the ip set at 9 with auto..PS 4) it worked out. Tomorrow is the day. WE shall see what they think of my cpap gymnastics.

Good job. If it helped the aerophagia and didn't allow a significant increase in OAs or hyponeas we can live with that.
I don't see how or why anyone should get their panties all in a wad over you making some changes...you still stayed within what was originally prescribed at the very beginning. Sometimes it isn't so much that we did the changes...they just get threatened by the fact that we know how to change things.
Their idea that you could reduce the pressure to 8/12 with the nasal mask might not have been so horrible if they had put you in auto mode instead of fixed mode.

So, went to the doctors. Once I showed them all my graph print outs (I said don't look too closely but this is what I am learning and how I can monitor my sleep apnea) I did a lot of "off the record" . She kind of knows my personality so she was mostly willing to work with it.

So, the compromise is 15/9 fixed. And the numbers look ok with that. I asked if I have an auto pap why do we not use the auto pap setting (then I talked about oh say 17/10 with a 4 PS setting)(just fer instance<g>) I =think= she felt the auto didn't allow them to measure my progress in a way they prefer. That the auto is a moving target. I think thats what she meant and I can understand that logic...if I wanted my health controlled in a fixed way. I will use the new fixed settings and see how they pan out. And then we will see. Oh, I did not have a chin strap or mouth tape. It happens. So that could be why for some of the events?

They were pretty impressed by Sleepyhead. Neither the dr nor the sleep technician was familiar with it but they were impressed (tried not to show it but I saw it )

WE talked about the nasal mask being better for me than the pillows because of the deviated septum. And I have tried several of both and the nasal mask is the most comfortable. Waiting for the new Airfit nasal mask and Ill let you all know how it is.

So here are the latest. Maybe time for a new topic heading
ResMed
S9 VPAP Auto
Mode: Bi-Level
EPAP: 0.0 IPAP: 0.0 cmH2O
PS: 0.0
Date Sleep Wake Hours
4/23/14 22:35 04:10 05:35:15
AHIApnea / Hypopnea Index 5.91
HypopneaHypopnea 0.00
ApneaUnspecified Apnea 0.00
ObstructiveObstructive Apnea 4.47
Clear AirwayClear Airway Apnea 1.43

Event Breakdown


Statistics
Channel Min Med 95% Max
EPAPExpiratory Pressure (cmH20)
W-Avg: 8.97 4.66 9.00 9.00 9.00
IPAPInspiratory Pressure (cmH20)
W-Avg: 14.97 10.66 15.00 15.00 15.00
Minute Vent.Minute Ventilation (L/min)
W-Avg: 6.14 0.00 6.12 8.00 11.38
Resp. RateRespiratory Rate (breaths/min)
W-Avg: 14.04 0.00 14.20 16.80 20.40
Resp EventsRespiratory Events
W-Avg: 0.00 0.00 0.00 0.00 0.00
Flow LimitFlow Limit Graph (0-1)
W-Avg: 0.00 0.00 0.00 0.00 0.13
LeaksLeak Rate (L/min)
W-Avg: 3.17 0.00 1.20 16.80 22.80
SnoreSnore (unknown)
W-Avg: 0.03 0.00 0.02 0.06 0.12
I:EInspiratory:Expiratory (ratio)
W-Avg: 39.24 10.00 40.00 50.00 69.00
Insp TimeInspiratory Time (seconds)
W-Avg: 1.20 0.00 1.18 1.42 1.60
Exp TimeExpiratory Time (seconds)
W-Avg: 3.14 0.00 2.98 4.40 7.54
Tidal VolumeTidal Volume (ml)
W-Avg: 431.97 0.00 420.00 560.00 760.00

Machine Settings
Pr. ReliefPressure Relief None

Session Information
SessionID On Date Start End
CPAP Sessions
1398306940ResMed CPAP 5h, 35m, 15s 4/23/14 22:35 04:10

lliann wrote:So, the compromise is 15/9 fixed. And the numbers look ok with that. I asked if I have an auto pap why do we not use the auto pap setting (then I talked about oh say 17/10 with a 4 PS setting)(just fer instance<g>)

and

So here are the latest. Maybe time for a new topic heading
...
Date Sleep Wake Hours
4/23/14 22:35 04:10 05:35:15
AHIApnea / Hypopnea Index 5.91
HypopneaHypopnea 0.00
ApneaUnspecified Apnea 0.00
ObstructiveObstructive Apnea 4.47
Clear AirwayClear Airway Apnea 1.43

The number of OAs is up, perhaps not to alarming levels, but they are up to almost 5.0. It is well worth watching the number of OAs like a hawk. While one night does not make a trend, you do need to watch the OAI. And if you start to see an OAI > 5 on a pretty regular basis, then you'll need to contact the doc again. And maybe at that point the doc will have the good sense to understand that a tight auto range might do a better job of balancing the need to minimize pressure to prevent the aerophagia while providing enough pressure to prevent the obstructive events when they start to happen.

And my guess is that the 15/9 fixed pressure might NOT keep the OAs completely under control, whereas a tight auto range would help keep the OAs under control without triggering too much unnecessary aerophagia.

FWIW...I agree with Robysue

That EPAP of 9 fixed..isn't likely going to get the job done. Need more nights to be sure but I have my doubts as to whether it will improve all that much with time.
I don't like the OA count either...and EPAP is what we look at when we don't like OA count.
Maybe last night was a fluke..maybe tonight will be a lot better.

I think I was the one who suggested the 9 epap because at 10 I was getting the aerophagia. At 9, not so much. But I could increase it in increments of .2, yes?

So what if theses numbers stay the same (say I do this for a week and Ill report if it varies up or down . I don't want to keep bothering you guys with my graphs every day(unless you plead me to )

Do you still go by the 17/10 (or 9 with the ps 4) Or should I adjust the fixed to say 16/10 first? I know she knows I play with it now and I did tell her that if my ahis go up, I will let her know sooner rather than later.

So the events happen on the exhale?

I don't know if the events happen for sure on exhale..they can but that's not the real reason we look at EPAP first.
EPAP is the base for holding the airway open. Prevent mode vs fix it mode sort of.

Your IPAP would have been the number I looked at more for reducing aerophagia issues (at least to start with) and not so much EPAP if we could get away from it.

If doing fixed pressure mode..I would think maybe 9.5 or 10.0 for EPAP and reign in IPAP as first choice to help reduce aerophagia chances.
Like IPAP at 14 and not 15.
9 and 15 fixed..that gives PS of 6...I would think PS of 4 or 5 would be just as comfortable and less chance for aerophagia to rear its ugly head.

But do give these settings a couple more nights (at least) before you go changing things because there is still a chance that last night was fluke "off" night. Those "off" fluke nights do happen. I get them myself. One night AHI is less than 1.0 and the next night over 5.0 and I change nothing...then next night back down to less than 1.0 again. I ignore the fluke nights.
Now if I had more bad nights than good nights..then I would look to making some changes. This is why we need to look at overall trends and patterns and not go chasing a single night's results.

So since it wouldn't be impossible for last night's result to be an "off" fluke night...I would give these settings a few more nights to see what it wants to do.
My gut tells me, since I have seen your other reports, that this may not be a fluke night...but my gut has been wrong before.

well, no idea what happened last night. Same settings as night before, same mask and I wore a chin strap (only difference) and my ahi went up. I do see most of the centrals happened as I was waking.

Sleep position change maybe?

I wouldn't give it much longer with fixed 9 EPAP...if it were me. But then I am not known for my patience when things are this horrible looking. borderline horrible....I have some patience but not when things look like this and not based on where we were at with the other past experiments.
If 9 EPAP is needed/wanted to help out with aerophagia...it needs to be allowed to increase a little bit to help hold the airway open and prevent those OAs from ever forming.
And the only way to allow EPAP to increase a little bit is for auto mode to be used and allow either EPAP to go up or IPAP to drag it up. Tight range to limit aerophagia issues though.

Like auto mode...9 EPAP max IPAP 15 or 14 but use PS of 4. That would start the night out with 9/13 but allow a small range up to 11 EPAP and 15 IPAP if using max IPAP of 15.

If fixed mode is used...I anticipate 10 EPAP being needed but one could go up in 0.2 increments just in case they got lucky.

Honestly Pugsy (and Robysue), I am totally in line with your logic. I have no trouble upping the EPAP to 10. And see how the aerophagia compares. And then reducing.2 as needed. I am willing to try the fixed thing for a little while to see if we can find the sweet spot. If not, then I will go back to auto.

I think I understand the auto behavior and it seems so logical to me. It makes me wonder what might be the reasons for NOT using it. Could it train my system to start to forget to inhale and exhale without help?

lliann wrote: Could it train my system to start to forget to inhale and exhale without help?

No.
If that were the case it wouldn't matter which mode of operation someone used..These machines aren't ventilators despite it sort of half assed feeling like it at times.

Why your doc is resistant to auto mode...I have no idea. Some docs are just that way I guess. I understand wanting to take the pressure variations out of the equation for evaluation purposes but when using a very tight range...they aren't going to vary that much anyway because they can't.
Maybe with past patients she had someone do better with fixed and thinks everyone would/should do better.
It would be real easy to come up with fixed pressure settings that resolve your OSA....but your stomach would likely pay for it with aerophagia.

lliann,

Given the fact that you have problems with aerophagia that kick in when EPAP = 10 all night, but EPAP = 9 doesn't seem to be high enough to control the OAs, I really think that's a case for USING the AUTO mode of the machine. In Auto, the machine will be able to increase the EPAP to 10 (or more) when needed, but when your breathing is stable at EPAP = 9, the pressure will be left there. And so a very narrow auto range might both keep the OAs under control AND provide significant relief from the aerophagia that you feel with running with fixed EPAP = 10.

Could it train my system to start to forget to inhale and exhale without help?

As pugsy said, these machines are not ventilators and that's just not going to happen simply because you're in Auto mode.

Auto mode will simply allow you to have a working compromise between the needs of your stomach (EPAP = 9, please) and the needs of your airway (EPAP = 10 or 11 when things are "bad"). I'd suggest switching to a pretty tight Auto with settings

• Min EPAP = 9
  Max IPAP = 15
  PS = 4

That would allow the EPAP to range from 9 to 11, which should allow the machine to properly treat the OAs on a bad night without subjecting your poor tummy to the excess pressure on the good nights.

I also can't imagine why your doc is so opposed to switching you to Auto mode. Perhaps she just doesn't understand how sensitive your stomach is to that extra 1 cm of EPAP pressure.

For what it's worth, I wound up with the tight Auto range that I use on my PR System One BiPAP because it's exactly this kind of a compromise between the needs of my stomach and the needs of my airway. Back in Nov. 2010, I was titrated at IPAP = 8, EPAP = 6, and that was still hard on my stomach (although not as hard as CPAP at 9cm with EPR set to 3, which was effectively similar to using my bipap at 9/6.) In Feb. 2011 I had another titration study that resulted in pressures of 7/4, which the stomach had no trouble tolerating, but in practice it wasn't quite high enough to keep the OAs and snoring under control. So at my suggestion, the PA signed off on the idea of using my BiPAP in Auto mode with min EPAP = 4, max IPAP = 8. This allows my stomach to be comfortable on all but my "worst" nights when the BiPAP is running at 8/6 for most of the night in order to keep my AHI down where it needs to be. On more typical nights, the BiPAP is running at lower pressures (8/5 or 8/4) for much of the night and the stomach can tolerate small periods of time at 8/6 without it feeling like I swallowed a basketball.

It seems the one scenario I am understanding is that auto set and I was also thinking why not auto 15/9 with ps 4. I am even thinking 16/9 (if 15/9 isn't enough)because my old graphs showed I often went into the 16 territory. I did not show her, the dr, the charts from the auto because I was walking that fine line of letting her know I tried some things versus I wasn't agreeing with anything she said.<g>

I did 15/10 last night with mouth tape and it was crappy again. I read an old post of Pugsy about chin straps and tape creating their own negative affects on numbers. My best night was without something in/on/around my mouth. I think I get some real big air bubbles that can release slowly with a free mouth , but gather size and speed in my mouth and that creates more ahi's?

There is one other symptom I have been getting. A sore chest. I am not sure what the scenario has been for that so I need to keep watching for it. I almost want to say its those higher pressures of 16 and more. But if I took them, I guess I needed them (when it was set in auto)

I also can't seem to get past 4-5 hours with a mask on. But its better than nothing.

ResMed
S9 VPAP Auto
Mode: APAP 0-0cmH2O
Date Sleep Wake Hours
4/25/14 23:03 04:09 05:06:01
AHIApnea / Hypopnea Index 9.41
HypopneaHypopnea 0.39
ApneaUnspecified Apnea 0.00
ObstructiveObstructive Apnea 4.71
Clear AirwayClear Airway Apnea 4.31

Event Breakdown


Statistics
Channel Min Med 95% Max
EPAPExpiratory Pressure (cmH20)
W-Avg: 9.96 4.80 10.00 10.00 10.00
IPAPInspiratory Pressure (cmH20)
W-Avg: 14.96 9.80 15.00 15.00 15.00
Minute Vent.Minute Ventilation (L/min)
W-Avg: 5.31 1.88 5.25 7.38 10.75
Resp. RateRespiratory Rate (breaths/min)
W-Avg: 13.59 2.20 13.80 16.60 20.00
Resp EventsRespiratory Events
W-Avg: 0.00 0.00 0.00 0.00 0.00
Flow LimitFlow Limit Graph (0-1)
W-Avg: 0.00 0.00 0.00 0.00 0.17
LeaksLeak Rate (L/min)
W-Avg: 3.16 0.00 1.20 15.60 21.60
SnoreSnore (unknown)
W-Avg: 0.02 0.00 0.02 0.04 0.06
I:EInspiratory:Expiratory (ratio)
W-Avg: 40.92 5.00 41.00 54.00 73.00
Insp TimeInspiratory Time (seconds)
W-Avg: 1.28 0.56 1.26 1.52 1.80
Exp TimeExpiratory Time (seconds)
W-Avg: 3.24 1.04 3.02 4.78 8.50
Tidal VolumeTidal Volume (ml)
W-Avg: 388.82 100.00 380.00 560.00 740.00

Machine Settings
Pr. ReliefPressure Relief EPR x0

Session Information
SessionID On Date Start End
CPAP Sessions
1398481396ResMed CPAP 5h, 6m, 1s 4/25/14 23:03 04:09

got my new airfit masks today. May try the full face one just in case something monumental has changed with my ability to do full face<g> I am hoping the nasal one is as heavy headed as the wisp is.

lliann,

I still think your best bet is to switch to Auto with a narrow range. Since the doc is resistant, you're going to need to "persuade" her or "quietly go rogue."

Here's how I'd try to persuade the sleep doc into allowing/approving the switch:

You need to be open and honest that the compromise fixed setting of 15/9 is NOT reliably keeping the OAs under control, but that your stomach cannot handle 15/10 for the full night every single night. But also tell the doc that you think your stomach would be ok if the machine increased the EPAP to 10cm for short periods of time when the OAs are at their worst and reduced the pressure back down to 9cm when your breathing is stable. And that you'd like to be able to test that theory out with a very narrow AUTO range.

Lots of docs seem to think "Auto" means "Auto with the default, wide open settings", which on your machine would likely mean something like Min EPAP = 4, Max IPAP = 20 (or even 25), and PS = 4 (or so), and those settings WOULD be a DISASTER for you to use. So it may be up to you to let the doc know that your machine CAN be set in Auto with a very narrow range.