[Equipment] Adjustment to new machine?

[sleepysurgeon]

Hello and thank you for this wonderful board.

I have been using a Resmed Autoset S9 APAP with the Airfit P10 and the Swift FX nasal pillows for the last 5 years.

The results have been a life changer with immense improvement in sleep, total cure of gastric reflux and good improvement in blood pressures.

Since the machine is near the end of its rated life, I pre-emptively bought a new Dreamstation APAP (version 1) last week to use as my primary machine. I planned to keep my S9 as a backup machine.

I set up the Dreamstation with the same settings I used on my S9

• I am still using the same pillow masks that I used with the S9
  
• Start pressure 6 mmH2O, Max pressure 20 mmH2O
  
• Ramp on, 10 minutes
  
• AFlex on, Flex 2
  
• Mask type set to Pillows (Nuance)
  

My first two nights with the new Dreamstation have been disturbing to say the least:

1. I woke up multiple times in the night
2. The flow seems be much higher and tends to bloat my stomach and produce gas
3. I have an uncomfortable aching sensation in my chest from about the middle of the night
4. I wake up tired and exhausted
5. The max pressures are reaching 17-19 mmH2O compared to around 15 with the S9

• The AHIs have doubled from my usual 3 with the S9 to around 6.5 with the Dreamstation
  
• Despite the increased flow, there seem to be more vibratory snore events and obstructive events with the Dreamstation. Even a couple of clear airway obstructions.
  

I switched back to the S9 last night and the improvement was very noticeable, in the quality of sleep, the sleep data and pressures.

What is going on? 
It is just a case of having to adjust to the new machine?
Do I need to tweak any settings?
CPAP machines are not covered with my insurance so I paid for the new machine.
Should I just cut my losses and buy the Airsense 10 instead since the S9 is no longer manufactured?
I imported the Dreamstation so returning it is not an option.

I have asked a lot of questions, I know but thank you for the patient reading.

[staceyburke]

I owned a dreamstation for 5+ years and never (even using this site for help) got my events less than 22 a night. I got a resmed and dropped the events to <5 a night for the last 7 months. The dreamstation is not as fast to act on the events and the way they find the events is different also, making the dreamstation a much less effective therapy. I'm sure that money is tight (it sure is for me) But Supplier #2 is where I got my machine. It was slightly used (less than a month)- they also buy slightly used machines. I would give them a call and see how much you can get for your machine and the price for a used resmed S10 autoset or autoset for her....

the list of suppliers is at the top of the page.

[Crimson Nape]

Hi sleepysurgeon!  -  

It is possible to achieve a reasonable level of therapy from the Philips machine, but you just have to learn how it plays the game. The Resmed algorithms are more advanced in design than the Philips models. For this reason most here use the Resmed.  Coming from an S9 to a Dreamstation is a real culture shock.  A Dreamstation does not respond as fast, or the same way, to hypopneas and OAs as does the Resmed.  For this reason, you need to increase the starting minimum pressure higher on the Philips.   If you are looking at the pressure graph on the Philips, you will see periodic spikes in the pressure.  This is Philip's way of testing to see if more pressure is needed and is not a cause for concern.  The AFlex, while similar to EPR, is not a direct replacement.  You will not experience the same level of therapy or comfort using the AFlex as opposed to the EPR option.

This is just a guess, but I would set the starting pressure to a value somewhere between the Med and 95%-tile readings.  The vast pressure range you currently have set can be a cause for sleep disturbance.

Since it is your money and time, I think you might give it a week and then, if you are still uncomfortable, consider acquiring an S10.

Please keep us posted on your journey either way.

Good luck!

[sleepysurgeon]

I am attaching three screenshots of OSCAR data for anyone who might be able to help me out with modifying settings:

1. A typical daily readout when I was using the S9

   

2. The last day's readout from the Dreamstation

   

3. When I switched back to the S9

   

[Crimson Nape]

Here is my observation.

Some of your apneas are positional, either chin tucking or supine. Work on your sleeping position.

Looking at your Flow Limits on the S9, you would be better using an EPR of 3, no ramp, raising your starting pressure to 9 cm and the max being 16 cm.

Trying about the same on the Dreamstation; I would leave the AFlex to 2, no ramp, minimum pressure 12 cm (to account for its slow response to OAs) and maximum to 16 cm. The reason for limiting the pressure, is because too large a pressure range can cause arousals. Sometimes letting a few apneas slip through is more restful than trying to get them all.

What are your thoughts?

[SarcasticDave94]

Another observation, with the ResMed S9 you could get away with less than ideal pressures and still do very good. The Respironics doesn't play that way, you'll need to tune it a lot to get very near your needed pressures. It may work well after pressure set goes up as Crimson Nape's mentioning. The problem is you may find that getting a Respironics to treat Apnea better it may sacrifice your comfort.

[sleepysurgeon]

Thank you to all of you who responded!
Some very useful suggestions! 

I made a few changes to my settings:

1. Changed AFlex to 1 - the EPR on the S9 was at 1 - so to mimic that setting
   
2. Turned Ramp off - to reduce the time to therapeutic pressure
   
3. Reduced minimum to 6  - based on the suggestion that higher baseline pressures may cause bloating and increase discomfort
   
4. Reduced max to 16 - to prevent the algorithm from overcompensating for false positives.
   

I did sleep much better.
No bloating at all today.

Just few things I am concerned about:
The 95% was at the max 16 - which is sort of expected given the readings of the past couple of nights.
AHI went up further to 7.1 (very few false positives) - again, sort of exchanging therapeutic pressures for more comfort and sleep.

The machine did not record the flow rate for the first part of the night. - No idea why. The SD card was in the slot for the entire night.
   
Woke me up with a series of alarms and an error code on the screen. I reset the machine by powering on and off, thereafter it behaved as it should.
I should have recorded the error code but was too disoriented and sleepy in the middle of the night when this happened.

I just downloaded the service manual from this board and I seem to have done the right maneuver serendipitously.
   

[Gideon]

You have positional apnea on both the S9 and the Dreamstation. Read the Soft Cervical Collar link in my signature. It could be an issue with pillows, typically too many or not flat enough. This is something that pressure will not resolve The 'tell' is the clusters of obstructive events. A little on the S9 and more showing on the Dreamstation.

The lowest min you should be using is 8, IMHO 10 would be better, with an eye toward moving it up. On the Max, the clusters of obstructive events is driving your pressure up. We NEED to fix these clusters.

For now, and for comfort, set max pressure to 13. You are not accomplishing anything by going above that. Note that this is just above the original suggestion of a min of 12.

On machines, this is one reason why we strongly recommend ResMed. Another is EPR actually treats RERAs, Flow Limits, Hypopneas UARS. Note that you have RERAs poking the on the Dreamstation. We will help you no matter what machine you are using.

[sleepysurgeon]

You have positional apnea on both the S9 and the Dreamstation. Read the Soft Cervical Collar link in my signature.  It could be an issue with pillows, typically too many or not flat enough.  This is something that pressure will not resolve The 'tell' is the clusters of obstructive events.  A little on the S9 and more showing on the Dreamstation.

Thank you so much for taking time to reply.

Yes. I do have a problem with pillows. I used to use 3 pillows while using the ResMed and moved down to 2 for the Dreamstation.

My cervical spine gives me hell the next day if I don't! 

I did try using a cervical collar for a week about a year ago to stop chin drop but found it too difficult to sleep. It also gave me nightmares about people trying to choke me! 

Maybe I should DIY a custom pillow which gives me the required height as well as prevents chin drop.