[CPAP] Newby trying to understand what i am seeing

[WoodyV12]

]Hi All

 please

I have recently been diagnosed with SA and been thru the machine testing and selection process. The Sleep clinic hasn't been over helpful as their main aim seemss to be running a business which is fair enough but a bit frustration when they have all the info and reluctant to share. Given that I believe that the only person who is responsible for your health is yourself it behoves me to educate myself on the use of the CPAP device.

Diagnosed on Dec 7 2023
Key Indices
Arousal Index 14.8/hr
Resp Dist Index 20.4/hr
Aponea Hyponea Index 18.3/hr
Longest Aponea 36.7 sec
Minimum SaO2 82%

Started with a Resmed 10 something. Immediate improvement  morning .. not exactly jumping out of be but nowhere near drowsy and lethargic as before.
API dropped below 5/hr, but still had Aponea with the longest @ 18.4 sec.

Sleep clinic couldn't/would'nt give an explanation or solution.. implied that there wasn't much more the machine could do, but on subsequent visit at my insintense volunteered that maybe the Lowenstein might be a solution as it was "gentler". Felt better with new machine and decided to buy.  Going back to clinic in a month for "review" ($80) but not
expecting much.  Hence the post

Here are a couple of screenshots that indicate continued sleep interruptions. The only change in settings fromm the start is to up the pressure from 15.00 to 16.00 that didn't seem to change much and changing to APAP. There are multiple RERA events all night. Are these an issue and if so should we be altering settings?

       
Cheers and thanks in advance
Jen

[OpalRose]

Did you have the same high rate of Flow limitation and Reras when you trialed the ResMed?  

Not knowing a lot about how SoftPap works, I'll assume it's similar to ResMed's EPR.

Try changing the SoftPap setting to the highest it will go, I think it should be 3.

Also, be aware of how you are  sleeping and that you're not purposely cutting off your air by what we call "chin tucking".  If on your back, be sure your head is not being pushed forward into your chest by a too tall of a pillow. If on your side, be sure you're not tucking your chin to your chest.  

The high FL and Reras need corrected. This is usually taken care of by using higher EPR or Pressure Support (ResMed). Have you talked to your doctor about trying a BiLevel machine? Preferably a Resmed AirCurve 10 VAuto.

[WoodyV12]

Thanks Opal

Answering in Order
Pressures
Yes..same pressures initially, then increased based on pressures max increased from 15 to 16 last week...no visible change..except now hitting 15.9 occasionally

Softpap
Looks like it is the same.. Lowenstein has 3 settings, Off, Slight and Standard.. I've swapped to standard for tonight to see what happens

Chin tuck
Pillows could be issue.. I am propped up in bed .. I'll rearrange tomorrow to identify only one chang at a time

BiPap
Yes, Did ask about BiPap but was told they are only used in hospitals.. (dismissive answer as I have come to expect.)
I did get a reaction on last visit and a bit more communication when I put print report from Oscar in machine case for "Sleep Specialist" to find.


Cheers

Jen

[CPAPfriend]

Typically they don't really even know what they're doing, but it's possible they're trying to lure you with additional appointments. You've found the right place! Without zero doubt, there is no better place on the planet I've yet found where one can get better PAP advice, and the kicker is it's even free.

I agree with Opal's recommendations. You have textbook flow limitations, and resolving them is best done by increasing pressure support (or soft pap in this case). If raising to 'standard' is insufficient, it may be worth considering a bipap, as you can kind of start off where softpap maxes out and keep going.

Good luck tonight, and I have high hopes for you

[WoodyV12]

Update
Removed all the pillows the bar one designed for Cpap use provided by the sleep clinic
Changed Softpap to 3
Changed mask as full face was causing irritation and inflammation on nose bridge... (Unbranded)
Now trialling a Resmed F30 and F30i. Both are more comfortable but prone to a higher leak level
... will try a slightly firmer fit if and will trial Resmed full face next week if no change.
Pillow is quite hard so getting a Resmed pillow that is slightly different shape and softer
Not due to go back to Sleep Clinic for a few weeks so rather stuck with discussing if Bipap is more appropriate
Will also attempt to get copies of trial data from Resmed 10 for reference.

[Macka]

Softpap is not the same as epr. The Prisma range use a different algorthm on level 1 and 2 (bi-level) and a different one again for level 3 (tri-level). This is also variable and increases pressure support as pressure increases. The algorithm for level 1 and 2 lowers epap in increments of 1cmH2o at lower pressures, 1.25cmH2o at midrange pressures and 1.5cmH2o at higher pressures. It also is very different in its delivery to resmed, as it begins the ramp back to ipap pressure immediately after hitting epap.

Level 3 applies epap at the same scale as level 1 & 2, but adds a breath triggered, extra 1cm to ipap, giving variable pressure support upto 4cmH2o on higher pressures.. If you look at the waveforms, this mode is designed for resolution of flow limitations and reras. It also nicely follows your breathing much better than level 1 or 2 in my experience. It is as if the whole mode (tri-level) is tuned better with trigger and latency.

   

The mask pressure trace shows clearly the uniform ramp rate used for the first part of each breath returning to ipap pressure in this trace, but then at 12cmH2o the tri-level kicks in to tackle the flow limitations. I have instability here and this is a good section. I am at the limit of tolerance for aerophasia and how far a regular machine can take me before bipap is needed. I own Airsense 10 as well. It cannot do this.

It is a shame this maker is kept out of the US as there is not enough people working with maximising this machine. It is far superior IMO. The lowenstein bilevel and asv machines use these advanced algorithms. I am currently trying to get my hands on one of their bilevel.

Jen, that was probably mumbo jumbo at this stage for you sorry!
 
In order to see how far your current machine can take you, softpap 3 with raised minimum pressure would be the place to start. Also set the machine to dynamic mode.
Your long ramp at a low min pressure looks to be unsettling you right from the start as well. A good direction would seem to me, raising your minimum pressures overall and limiting or eliminating ramp time.
At higher pressures the Vcom works really well with the Prisma, without reducing its effectiveness. That chart above is with a vcom in place at the machine end. I reach all my max pressures during inspiration. Without the Vcom in place my flow limitations really take off.

[Sleeprider]

Macka, this is fascinating and important to know in how to best utilize the features of the Lowenstein Prisma 20A. If you would like to join our wiki editor team, I'd like to see an article on this. If not, maybe you could help me to develop a wiki to discuss this and other features that help optimize the Lowenstein. Here is a link to the Wiki stub https://www.apneaboard.com/wiki/index.ph...ptimiztion Please feel free to provide edit or become a wiki editor. https://www.apneaboard.com/wiki/index.ph...iki_Editor

[WoodyV12]

Hi Macka

Thanks for help
We have been working thru Resmed masks and at this stage settled on F20 with Soft cushion. 
Seems to be the only one with minimal leaks with a bonus that it's actually comfortable when cushion added.
Resmed have been very patient and helpful - brilliant!

First Night F20 -No Cushion - App Standard - Ramp on
   

Second night  F20 added cushion -  Apap standard - Ramp Off
         

Seems like an improvement to me.. definitely feel better in  morning.
Will set dynamic..Chart in next post

[WoodyV12]

Hi Macka

Set Dynamic.. not sure if that improves much

   

[Macka]

Hi Jen, you are definitely moving in the right direction. It will be helpful if we get your Oscar display more coherant so it is easier to focus on the data that is most helpful. Here for general advice;

https://www.apneaboard.com/wiki/index.ph...ganization

...and more specific to Lowenstein;

   

The dynamic setting is not seen in effect because you're being taken straight to your max pressure by the machine quite quickly. On one of the previous night on standard setting you did not go so quickly to max pressure. One night is not conclusive but that could be what happened there. I would leave dynamic on as you have a lot of flow limitation and reras which it is designed to respond to. Once we can see your flow rates more clearly we can look at tackling those flow limitations.