APAP or CPAP? Very confused

robysue wrote:

zoocrewphoto wrote:

BlackSpinner wrote: Normally ramp is set starting at 4 You really think a newbie is helped by starting them at 8 ?!? Most people are asleep by the time the ramp get up to 8 -10 -12 after 15 -20 minutes. THERE IS NO THERAPEUTIC VALUE TO RAMP. It is training wheels. If it takes her a month or two of hitting the ramp button at 4 for a while it doesn't matter. The cpap is useless unless she can keep it on - the ramp starting at 4 is to get her used to it - just like training wheels on a bike. It is absolutely counter productive to put some one on a ramp starting at 8, they will give up.

For that matter that 12 reading might be due to leaks - nobody knows, it was just a guess.

Most people struggle at 4 and thus fail at cpap. They never get past the ramp because they are fighting with the low start pressure. I see no reason at all to ever start somebody at 4.

Zoocrewphoto:

YOU are uncomfortable breathing at 4cm. But that does NOT mean EVERYBODY is uncomfortable breathing at 4cm. There are as many people who FAIL at CPAP because they can't get used to the hurricane of pressure that they've been prescribed as there are people who give up because they "can't breathe" because the pressure is too low.

In this case Luthie2006 cannot tolerate 8cm of pressure because it hurts to breathe and the pressure feels TOO much. She has had some nights previously where she DID get through the ramp period when the ramp was set to start at 4cm.

BlackSpinner is right here: Having the ramp start at 8cm is doing NOTHING for Luthie since she can't stand that much pressure (yet) when she's awake. Luthie's ramp SHOULD be set to 4cm so that LUTHIE is more comfortable.

My concern is that many newbies feel like they can't handle the air pressure, but when we ask them about it, it turns out that it was really too low and not too much.

I know there will be very different reactions and perceptions. But I remember within the first week thinking that the machine had stopped as I couldn't feel the air. I had to bump my mask or wave my hand in front of the mask to feel the air venting out. My minimum was 11.

The OP has been using a machine that has been reaching 12 at least, possibly 14 from the sounds of it. So, with some practice, she should be okay with 8 and 10.

Also, if the ramp goes back to 4, and she keeps hitting the ramp, she may not get any therapy at all. She may be having trouble sleeping because she is having events. It doesn't take much to doze off, have an event, and then feel like you never fell asleep.

Good morning everyone: A few comments: Someone wrote I did not add my age, and therefore cannot participate in the conversation? I am a young 62. As far as being lied to by my sleep clinician, I know she would not lie to me and tell me that the ramp feature only goes to 20 minutes. Perhaps she does not know it goes longer. She told me the longest it goes is 20 minutes. I am glad that everyone told me that it goes to 45 minutes because I will tell her that on the phone this morning after I drop the machine off. I guess it's a matter of finding all the right numbers, as I had a home sleep study test and not a lab test at the hospital, so we are just "willy-nilly" trying to find the right numbers. I usually have no problem falling asleep without the machine, but like someone wrote, when the ramp goes off and I am laying there, I am trying to keep up with the 12 pressure air and on 3 EPR. So we will continue to work on numbers. Thank you for all your support. I am not giving up (yet).

Luthie2006 wrote:As far as being lied to by my sleep clinician, I know she would not lie to me and tell me that the ramp feature only goes to 20 minutes. Perhaps she does not know it goes longer.

The default is 45. She had to change it to 20 with her own hands. She knows. She lied.

The Latinist wrote:

Luthie2006 wrote:As far as being lied to by my sleep clinician, I know she would not lie to me and tell me that the ramp feature only goes to 20 minutes. Perhaps she does not know it goes longer.

The default is 45. She had to change it to 20 with her own hands. She knows. She lied.

This webpage shows all the settings, including defaults.

http://www.sleeprxonline.com/productinf ... _guide.pdf

And yes, the default setting is 45 minutes.

Unfortunately, most DME employees lie. It seems to be the standard, and they lie about things that are easy to prove wrong. My first DME lied to me when I asked for the small size headgear for my mask. They told me it didn't come in a small size. I forwarded them the email fro Resmed with the order number along with a link from cpap.com showing the small head gear. They replied that they could not order it. I fired them and got it less than a week later from my new DME. If they would lie about something so easy to prove wrong, what else do they lie about?

This was the reply back this morning from my sleep clinician at the hospital (She does not work with the DME)
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I already changed your machine settings this morning.

1. Reduced CPAP low pressure of 12cm to 10cm
2. Increased ramp time from 20 to 30 minutes
3. Decreased Ramp start pressure of 8cm to 6cm

Your friend is right, the default ramp time is 45 minutes on the ResMed S9. A little too long for most patients.
20-30 minutes is usually pretty good starting out as a new CPAP patient. As a person becomes accustomed to
the pressure the ramp time can be decreased and usually people ask for it to be disengaged.

My weekend was great...Except for the Blackhawks not winning the Western playoffs.

Your CPAP is back upstairs, ready for you to take home. Let me know how it goes.
________________________________________________________________________________________________---
Is this accurate? Thank you so much!

1. Reduced CPAP low pressure of 12cm to 10cm
2. Increased ramp time from 20 to 30 minutes
3. Decreased Ramp start pressure of 8cm to 6cm

That sounds much better. Hopefully the 6 cm will feel much more comfortable to you.

Thank you Black Spinner: However, the reason why in the first place my sleep clinician changed my original setting from 4 to ramp at 8 when my pressure was going up to 12 and 14, is that I was being awakened every hour. I don't know if 6 will be any better at not waking me up. She thought that the sudden change in pressure to 12 or actually in my case after starting at 4 pressure was waking me up every hour.

Luthie2006 wrote:Thank you Black Spinner: However, the reason why in the first place my sleep clinician changed my original setting from 4 to ramp at 8 when my pressure was going up to 12 and 14, is that I was being awakened every hour. I don't know if 6 will be any better at not waking me up. She thought that the sudden change in pressure to 12 or actually in my case after starting at 4 pressure was waking me up every hour.

If you find that you are waking up frequently, download your data and post the graphs. It will help to see what your pressure is doing, if you having a lot of events, etc.

I cannot win for losing! I was up in every single part of my REM sleep last night. My numbers look very good, but for some reason I am up when I get into REM sleep because I remember every dream as I am waking up; tons of different dreams; one small nightmare, one bathroom trip and very tired in the morning and all day long.

Ok, pressures are reset now by the sleep clinician.

10-20 - ramp starting now at 6 for 30 minute which I think feels a little low. I may try to figure how to up the ramp to 7 or 8 with some help.

Looked at the machine this morning: Mr. Green Smiley on

Sleeping with mask and machine on 8.3 hours (looks good but up 3 times dreaming and nightmare (trying to solve investigation with investigators) and one bathroom trip)
Pressure 13.0
AHI - 0.0
Leaks 21.0

I don't know why I can't get through any REM sleep and am exhausted this morning. Do some people with/without apnea wake up through REM sleep? These numbers don't match what is clinically happening to me.

Luthie2006 wrote:Leaks 21.0

Assuming that this number is from the S9 LCD screen...that's a 95% number which means that for 95% of the time at or below that number...and while not horrible by any means it points to some leaking and maybe the pressure increasing during probably REM sleep is also causing mask leaks or mouth opening which might impact things and cause you to wake up.

Your leak number to avoid is 24 L/min if at all possible. While not the end of the world if we spend time up above it that is short lived we want to avoid it when we can.
When pressures go from your ramp of 6 up to your apap minimum of 10 and then up to the 13 you report seeing...hey , it's sometimes hard to make an adjustment at the beginning of the night with the mask that covers that 13 cm pressure...or maybe some mouth opening is going on.

So use the software and compare the leak graph with pressure graph with known awake times to see if you spot anything that might answer some of your questions. Maybe it's one or the other ...pressure or leak...or maybe just one that is causing the wake ups....and maybe it is just the newness of having the alien being stuck on your face playing a big factor.

What do you do when you wake up? How long do you stay awake? Is this something that just started happening with cpap therapy or did you have it happen prior to cpap therapy?

Thank you for writing, Pugsy: I am all confused now. I probably can rule one thing out: The "newness" of everything is not bad for me and I feel is not a problem, although now the ramping at 6 seems too low now. Can you tell me how to change the ramping to 7 or 8? Thank you.

I wake up during REM sleep all the time. I don't know why. My leak of 21 is acceptable I was told by the sleep clinician. My dreams are so vivid at the time I wake up. I don't wake up for too long, but I feel it is so often because of the number of vivid dreams, and I feel like I am not sleeping when I have these vivid dreams. I absolutely woke up like this too before the CPAP and had vivid dreams that go on and on like a movie in color. I was hoping that the CPAP would eliminate this. Some good dreams, some not so good. I want the 'movies" to stop because they are exhausting to "watch." I pretty much fall back asleep again for the most part, but back to more dreams. My numbers look very good, no apnea events at all whatsoever. (0.0) (at least last night and the other time was 0.4) I am not real tech savy, and would not know how to dowload graphs or even capture them if I could find the graphs.
My sleep clinician thought that I was being awokened by the pressure going up and that is why she lowered it down to 10. I don't feel actually at all that the machine or mask is bugging me at all, except I do want to up the ramp to 7 or 8 from 6. Can you please tell me how to do that? Do you have any other advice? Do some people absolutely not sleep in REM even with CPAP? Thank you so much.

You could be having more REM because you were REM deprived before cpap. Which means your body is trying to catch up.

Do like pugsy says and install sleepyhead software so we can see the cycles. Then it can be determined if there are issues at REM time that the machine should be taking care off.

Changing the ramp starting pressure is easy but you do have to go into the clinical setup menu to do it.
It isn't rocket science though.
Go here and review the steps needed to get into the clinical setup menu
http://www.apneaboard.com/resmed-s9-cpap-setup
and go here to watch the video to help reaffirm and see those steps in action. It will help you understand your machine a little better
http://www.cpaplibrary.com/machines.html

Please become familiar with the software (links in my signature line) you can use and how to post images of the detailed reports
Screen shot thread viewtopic.php?f=1&t=81072&p=737779#p737779

It's impossible for us to do more than guess at what might be going on in your situation with limited number data only.

Did you know that we dream in other stages of sleep besides REM sleep? It's not limited to REM stage.
REM sleep normally runs in a pattern with the first REM stage sleep happening about 90 minutes after sleep onset and as the night goes on we see REM come on more frequently and last longer.

And while it is common for OSA to be worse in REM or need more pressure in REM it is also possible to have similar effects while supine sleeping or both.
Are the apnea events waking you up? It's possible. Very possible in fact. And it is said that we are more apt to remember our dreams if we wake up during one. I don't know how set in concrete that statement happens to be.
My OSA is documented (in a sleep lab) being much, much worse in REM sleep and prior to CPAP therapy I didn't remember having any dreams for years. I was waking up (or at least arousals) a gazillion times during REM stage sleep but I wasn't remembering any of them.

So even if your "numbers" are good in terms of AHI reduction and control ....maybe it's a low level arousal from something that is causing you to wake up. It's impossible to know with any certainty exactly what is going on without EEG brainwave data to confirm sleep stage.
Leaks...yes 21 L/min is still within acceptable range in terms of therapy effectiveness but did you know that some people will have arousals or awakenings even with tiny leaks?
Some people can sleep through massive leaks (that would be me) and others will wake up with as little as a 5 L/min leak.

Do you take any meds of any kind? Even OTC? If so what is it, what dose and when do you take it?

Oh....FWIW....it took me over 2 months to get used to having the alien stuck on my face and not wake up a bunch of times just to feel it on my face and I adjusted well initially to the mask and pressures and all that.
You are still fighting pressure adjustment...your desire to adjust ramp tells me that.

I would really like to see a detailed report from your software reports.
One that shows events, pressure, leak and flow rate. There's no way to know just how often your pressures are changing without seeing it and changing pressures themselves can disrupt sleep...meaning you might do better with a very tight range in apap mode or even cpap mode. Gotta see what the pressure is wanting to do though..otherwise just making blind guesses.

Oh...this is typical pattern for sleep stages that show REM stages and how they progress as the night goes on.
If you are waking "from a dream" within 30 minutes of sleep onset...it might be from a dream in a different sleep stage or maybe REM rebound is going on. Not everything can be fixed with cpap machine though. It fixes bad sleep related to sleep apnea stuff. It can't fix bad sleep related to things outside sleep apnea and not all bad sleep is from sleep apnea.

So....meds question please?
and can you get comfortable with the software please....otherwise we really have no idea at all what is going on and it's hard enough to get any ideas when we do have the reports available.

See this link and scroll down a bit to see the hypnogram of sleep stages...it's down a bit on the right side.
http://en.wikipedia.org/wiki/Sleep

Thanks Pugsy and Black Spinner: I appreciate your information very much. As far as meds, yes, I am on some for chronic low back pain:
Celebrex 200 mg every day
Cymbalta (for low back pain 60 mg every day) Although I do realize this can cause insomnia, I don't feel I really have insomnia, just a lot of awakenings with dreams. The other me is a proton pump inhibitor, and a small 10mg of Lisinopril to keep bp down. I asked my Primary if I can wean off the Cymbalta for low-back pain, and see if it is the Celebrex that is working or the Cymbalta. We are not sure which med is working for the low-back pain, since he gave me both at the same time because the pain was so bad. (degenerative disc disease) and since Cymbalta has such horrible wean-off effects, to stay on both. Been on these 2 meds since November of 2013 when my pain was a "10" on the pain scale. It is maintained at about a 0-2 now. Do you think the Cymbalta is causing awakenings? I don't remember before I started taking in November because the pain was so horrible. Spine doc says no surgery which I am happy about. I guess it may be safe to say that when I looked at the LCD this morning, and saw 0.0 on the AHI, then I had no apneas last night with the mask.
It is complicated and I will try and see if I can dowload the information when I get home. Thank you all so much! Luthie2006 (Sandi)

Frequent unwanted awakenings from sleep...called sleep maintenance insomnia. Now I know you don't think you have insomnia but you do. Just by definition if nothing else which is trouble staying asleep.

Nausea, somnolence, insomnia, and dizziness are the main side effects, reported by about 10% to 20% of patients
http://en.wikipedia.org/wiki/Duloxetine
Weird that a med can cause both insomnia and somnolence (sleepiness) but it happens all the time. One person gets knocked on their butt and can't stay awake and the other is up cleaning house at 2 AM. Just the different way people react to the same medicine.

I also have bad arthritis and my daytime pain pill comes with a "may cause drowsiness" sticker but in fine print one of the side effects is insomnia...and I drew the short straw on that one. If I take it after 6 PM I have a gazillion wakeups...if I don't take it I get a gazillion wake ups from pain...talk about damned if you do and damned if you don't. Anyway, I have worked with my doctor to find something to help with the pain at bedtime and not cause me to wake up so many times because I didn't like being up cleaning house at 2 AM (no matter how much it might need it).

Your Cymbalta could very well be a factor in your wake ups.
It's general classification drug category is one with well known effects on sleep architecture...insomnia being common.

Celebrex isn't known to be much of a culprit in terms of messing with sleep quality.
Lisinopril isn't known to be a culprit for sleep quality either.

My bet is that the Cymbalta is playing a part in your awakenings. Maybe not 100% totally to blame but likely a significant part. If you are bored you can google Cymbalta and effects on sleep architecture if you wish. Don't get put off by the "depression" part of the discussions...it's just something that Cymbalta is also prescribed for.
That's one of the reasons I declined ever starting Cymbalta for my pain issues at night. Didn't want to get on that slippery slope.

Finally part of the awakenings could simply be low level pain in some form that's the very reason you take Cymbalta.
I don't know about you but I am never totally pain free. That's been so long ago that happened that I really have forgotten what it was like.