New to CPAP - Need advice!

[avaholic]

Can you shorten that segment to 2-minutes so we can clearly see the wave form?  I already see a lot of flow limits and can also see you expiration rebounding positive which is the flex kicking in at the wrong time.

My pleasure! As requested.
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[Sleeprider]

I see a lot of flow limitation, and some of those OA, sure look like you're not totally obstructed. I'd like to see some more typical breathing without the events.  As far as what we see here, between 1:47:50 and 1:48:00 we see the inspiratory flow become more and more limited, with severe flattening of the flow rate following start of inspiration.  It nearly flat-lines to 1:48:10 where we have a recovery breath (arousal) followed by another increasing flow limitation to the second OA which lasts nearly 30 seconds.  At 1:48:55 you have lots of recovery breathing with very high volumes, which give way to flow limited breathing.  The final OA at 1:49:40 is an artifact of the reduction of flow rate from the recovery breathing, and you are actually just returning to normal.  The flat and downward sloping peaks are flow limitation.

If I could overcome the flow limitation, we could probably break the cycle, but the Philips doesn't have any pressure support tools to help with that. This sequence came from the Saturday chart you posted earlier.  What we see is that the Philips machine is near the minimum pressure when this sequence begins at 12.0 cm. It rapidly climbs to 16.0 at 02:20, but the event has already been over for 1/2 hour. This is what we refer to when we talk about the slow response of the Philips machines.  The Resmed would have been on top of this before it ever began as it is very sensitive to flow limitation.  So in this case, not only does the lack of EPR make the flow limitation worse, but the lack of response speed allows all of these events to occur before the machine even begins to climb out of the hole.  Do you see where we're going with this? Most likely higher minimum pressure. If you have the opportunity to change to a Resmed machine, you could tolerate these lower pressures because we would have different tools other than higher pressure to address it.

[avaholic]

Is this what you are looking for?
   

"I know of several forum members that used this information to request a change of machines to Resmed and had these problems essentially disappear."

Sorry I'm not fully understanding exactly what you are referring to. What should I tell my doc that's not working on the Philips machine?

[Sleeprider]

Yes. I think your results would be better on a Resmed, and you should ask your doctor if he is willing to change your prescription to a Resmed Airsense 10 Autoset. He probably won't understand, so here is the rationale. Your AHI is still marginal to high in spite of pretty high pressures, and you're not feeling as rested as you should with therapy. You are using the machine, but it does not achieve the results you expect. In many cases, this would be enough to justify using bilevel, but really, it's just an artifact of the Philips Respironics Flex. A machine that followed your respiration, and provided real exhale pressure relief like the Resmed EPR, would not look like this. In this image we can see what is going on pretty clearly. You exhale and have good air-flow, but before exhale is complete, the machine is returning to inhale pressure. this causes the upward tick above zero before your real inhale begins. It may or may not be a good argument, but if you could try a Resmed for a couple nights you would immediately see the difference in rest and AHI. The inspiration/ expiration time being reported by your machine is 100% wrong. In this case, you might try turning off Flex altogether and see if it works, but I can assure you that using a Resmed with EPR you would be much more comfortable and have a lot better results.

[avaholic]

Thanks Sleeprider!

Do you feel that I would see no benefit from a bi-level unit like the Aircurve 10 VAUTO? Is all that I need is the Airsense 10 AUTOSET?

So now I guess my question becomes how do I even attempt to change devices since I've only been on therapy for 14 days now? 

As I mentioned in my first post, the DME with whom I have been working only carries Philips equipment because of 'contract issues with ResMed.' This DME is also affiliated with the hospital where my sleep doctor is. I'm concerned they're going to say well let's try the Philips bi-level unit and not want me to go somewhere else to get the ResMed. Will they even return this current Philips unit? I should clarify that my insurance is renting this unit for 12 months and then I would own it. This is all a bit overwhelming.

Last night was horrible again. I couldn't go to sleep and then after I actually did go to sleep the breathing issues resumed. Also note that unit is STILL dropping the session for one second while I'm asleep. It always happens between 1-1:30 am. Ugh!

Sunday
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[Sleeprider]

The Vauto is a great machine. Both the Airsense and Aircurve work the same, but the Aircurve offers many more tools including trigger/ cycle sensitivity, and adjustments in inspiration time (Ti) minimum and maximum that can actually ensure pressure support is sustained for the entire normal time of inhale. The Aircurve removes the 3-cm pressure support limit of the Airsense. I could easily use an Airsense 10 Autoset and get good results, but I made the effort to get the Vauto, and I hope to continue with that.

It is much harder to get a doctor, and especially insurance to approve bilevel, which is more expensive. So if you're not self-financing, then it is easier to get a change in auto CPAP than to upgrade to auto VPAP. That said, I would not hesitate to look for a Vauto that is lightly used or through a discounted source. Supplier #2 has the Vauto at $799 which is a pretty decent deal, but you can find them on Craigslist for much less. I guess it just depends on how far you want to take it.

You have some indications of complex apnea, and you may respond to bilevel or bilevel ASV. It is probably worth putting it out there for your doctor to make recommendations. Simply pointing out that your results are not satisfactory, and that the high event rate is uncomfortable and causing fatigue or functional impairment should be enough for the doctor to consider testing bilevel and possibly ASV to see if the central apnea components are responsive. That is probably a better approach than to simply request a change to Resmed. If continued CPAP is indicated, I would try for Resmed rather than Respironics, but it's probably best to get professional input, and if he is willing to try a bilevel titration or for a long-shot ASV titration, that would be outstanding.

As far as a DME that limits itself to Philips, I think that is ridiculous. I'm sure there is more than one in-network provider you can go to, and there is no reason to use any DME "because that is who the clinic/ hospital works with". That is a certain way to get into inappropriate financial arrangements. I would not want my choices limited in that way, any more than I would accept my bank stipulating what dealership I must buy a car from. I probably don't need to tell you the only reason your DME is "exclusively" Philips is because of a financial arrangement from the Philips distributor, and possibly the medical clinic.

[avaholic]

Yesterday, I spoke with my doctor and they did a download from the device of the 16 days its been used. She said that she does not see any indication of complex or mixed apnea warranting a bilevel or ASV titration at this time. She suggested that we might try to changing the minimum pressure on the device after my first check-up in 2-4 more weeks.

I told her again that was not resting well and not happy with my results. She said that with a starting AHI of 102 at my sleep study that an average of AHI 8-ish on CPAP was great. I also explained that I was having difficulty with the FLEX on the Philips unit and told her that I wanted 'real exhale pressure relief.' She said this 'feature on the Philips and ResMed devices are basically the same thing just named differently.' I wasn't going to argue so I just said OK. Ugh.

I also spoke with my insurance company and current DME about getting a ResMed device. I think this is going to turn into a big huge fiasco. The DME said I could return the unit but they warned that my insurance company would not agree to pay for another humidifier and tube since those were purchased outright and not leased. I think if anything, I won't have a device for at least a week of two while the two different DME's and my insurance work through it (if the insurance company agrees to even give a 'predetermination' in the first place.)

I have yet to try turning off flex altogether since I'm already having issues with air blowing in my mouth when I exhale. Won't that be constant pressure blowing in my mouth if I turn it off? How could that possibly help with my situation? I've been waking up still tired, yawning and have been having headaches during the day. 

I am getting a little frustrated with all this crap. 

Any other suggestions, comments (or encouragement for that matter) would be most appreciated!

Wednesday
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[Sleeprider]

A lot of your problem in my opinion derives from the flow limitations. Your doctor thinks an AHI around 10 is great news. I disagree. Your doctor is clueless about the difference in machines and how they deliver exhale pressure relief / Flex. I am not surprised, and find very few physicians are actually knowledgeable about the finer points of these machines. I agree you don't have a severe CA problem and ASV is probably not going to be needed, however something with bilevel pressure, from the 3-cm of an Airsense to higher pressure support of a bilevel will have benefits.

There is nothing wrong with being patient, but at some point I think you're entitled to better results and sleep.

[avaholic]

Thx Sleeprider. 

I should have mentioned in my previous post that not only have experienced frequent headaches but I've also been feeling dizzy the past few days as well.

I just got off the phone with the new DME. They were able to get approval from my insurance company to switch me to the ResMed Airsense 10 AutoSet. Fortunately, I won't be without a device at all since they will order the new unit and have it delivered to their office first. Then I'll take back the other unit and pick up the new one on the same day.

Note that when I asked my doc yesterday about the bilevel/ASV titration she said that insurance companies are very hesitant to approve bilevel devices and that I would have 'had to fail on all the other tests' (whatever the heck that means) in order for them to even consider approving the much more expensive machine.

Do you now feel that I won't benefit much from changing to the ResMed Airsense 10 AutoSet? Or do I need to wait and get a bilevel titration so I can possibly get approved for the VAUTO? You mentioned earlier that I would do much better on the ResMed 10 AutoSet.

[Rtype]

I have a Bi-Pap Dreamstation. After turning the FLEX feature OFF, it made all the difference in the world. I wish my provider team knew more about real world adjustments, but it is what it is. I had to stumble upon it by myself. I certainly want to encourage those who don't have good results with their current treatments to make reasonable adjustments to their own machines in conjunction with Sleepyhead software. Test other settings/pressures in your own real world conditions.