Are these flow limits my problem?

[Jay51]

Congratulations!

[Sleeprider]

Based on past results, I recommend a Resmed Aircurve 10 Vauto in Vauto mode with EPAP min 8.0, Max pressure 16, (EPAP max 12.0), PS 4.0 to start. After seeing the results, we can fine-tune. It will not surprise me if a slightly higher PS is eventually optimal. If your doctor can include these recommendations in the Rx with a recommendation for self-titration, you will have less problems with the DME, and that also covers any changes that may be required.

[k888]

Hmmm.  As soon as one thing is sorted out, the next presents itself.  I appreciate the setting suggestions (you know I would have been asking.) 
The doctor wrote the script during the appointment for min 5, max 11, ps 4.  I assumed these settings could be changed at home just like the CPAP machine.  Why does "self-titration" in the script make a difference? I don't understand the role of the DME in changing settings.  


The prescription calls for a Bilevel Auto EPAP (no brand even though I had specified in my note.) Under comments, it says machine exchange to bipap.
I did ask the doctor about a specific machine and she basically indicated it was up to me and the DME. I will call the DME to request a ResMed AirCurve 10 VAuto as soon as they open this morning.  Also, I can try to get a modified script with a specific machine – not sure how that will go as the operation overall is pretty sketchy.  Can I threaten to switch DME's if the situation involves switching out the machine?

Thanks for all your help, k888

[Sleeprider]

With 5-11 PS 4 your pressure range is 9/5 to 11/7. I have not seen EPAP that low in your previously submitted charts. Self titration in an RX is simply a license to make adjustments yourself and avoids some respiratory therapist at the DME telling you you're not allowed to make changes. It can be added at any time if that conflict develops. Nothing sacred about the DME-patient relationship. I switched last year when my DME arbitrarily cut off my supplies and refused to order a new machine without a new sleep study. As you know, that is not the DME's call. Their job is to order and dispense equipment and manage claims with insurance, not require studies unless insurance has denied a claim on that basis, or in your case, stipulate what brand/model device you should get. The Aircurve 10 Vauto is pretty much the only game in town, so I wouldn't worry about it.

[k888]

Thank you.  I did just call the DME and you are correct, the VAuto is the only bipap they are dispensing, so no worries on that front.  I will confirm the machine make before going in to swap machines, when that point arrives.  Re the pressure range, the Dr. did say my max pressure usage was 11, which puzzled me because I understood from OSCAR that it was higher than that at times every night.  Looking at the ResMed Compliance Report, I see the median pressure was 11.3.  I think that she got in her mind that that was the max pressure.  Thank you for all your guidance, k888

[Sleeprider]

Keep in mind that for obstructive apnea, the EPAP pressure is what stents the airway and pressure support is how we suppress flow limitation.  We have very little to work from, but in this chart you used EPR 3 and your median pressure was over 11/8 (IPAP/EPAP). We know the only OA event occurred at lower EPAP pressure.  I think your minimum EPAP pressure needs to be 6 or 7 and I went with 8 based on your median here.  When we add PS 4 to that, you're at 12/8. Even if we go to the absolute minimum, you're at 10/6.  Your doctor's maximum pressure of 11 is too low to accommodate your PS requirement on top of a prudent EPAP.  So you're welcome to start with a lower EPAP like 6.0, but  you still need a maximum pressure of 14 to 16 for titration purposes. I do think your median and 95% pressure will be lower with bilevel, but my thought was to give it some room and we can deal with optimization after a night or two.

[k888]

Sleeprider, your numbers and logic make sense to me.  Once I get the machine, project #1 will be to figure out how to get into the clininical menu.  Thanks so much to you and others for your time and patience. k888

[k888]

Good news!
I pick up my new Vauto on Monday.  Yay!  Thanks to you all for pointing me in the right direction and making it possible.
I have been trying to get my mind around settings for my current CPAP vs the new Vauto.  I'm not confidant I understand it, but I think I would like to start with:
EPAP 7, max IPAP 14, PS 4
Does this seem reasonable?
I went for lower numbers because I have had a problem with pressures over 13.4 on my CPAP.  Higher pressure results in more aerophagia and mask leaks that wake me up.  Apparently these are not large leaks, but the the air blowing on my face and mask rippling/farting really disturbs my sleep.  
Usually 13.4 works for high pressure.  Last night, it was not enough.  For much of the night, I was woken by air blowing and thought my collar was failing, so I kept repositioning.  Finally, I realized the pressure was too low, and I increased it to 13.6.   image below.  The only way I could keep that pressure up was by tightening the mask and allowing my cheeks to fill with air, which then stops leaks.  But it is also waking me up, so overall it was not a good night.  I'm hoping my pressure requirements will go down with the Vauto, giving me a little more wiggle room.  
   
•  In reading Deborah's thread, I see recommendations to increase Ti Max to 3.2. Is this something I should do as well?  I see that my inspiration time always exceeds the expiration time, though usually not as much as in last night's chart.
•  any other changes?

Thanks so very much for your thoughts, k888

[Sleeprider]

Your proposed settings will provide a range of 11/7 to 14/10. That is completely in-range for your previous CPAP experience and looks like you thought things through very well. The default TiMin 0.3 will not need changed. Your inspiration time with the CPAP and flow limits was abnormally long relative to expiration time, and our objective with pressure support is to see that fall well-below 3 seconds, but you should definitely provide 3.2 seconds of inspiration time (TiMax), and I would say if your median inspiration time actually exceeds 2.8 seconds we will look for more PS.

Congrats on the new Vauto. You will never look back.

[k888]

Thanks Sleeprider!  After years of being in denial about apnea, I never imagined I would be excited about getting a new sleep machine, but I am really looking forward to it.  k888