ResMed S9 Elite -- MANY apnea events still

[robysue]

I agree with your discussion of the terminology. In some sense, it doesn't matter, but in another, it is important for there to be common definitions so that correct communication occurs. I think the Auto CPAP is quite accurate and descriptive, but rarely used. The shortened version, APAP, is also accurate though not as clear to people who don't know it yet. CPAP now has become an aberration; if interpreted PURELY, it does not include APAPs (or whatever other variants of these there are...BiPAPs?? whatever that is). But many now are using the term CPAP to include ALL air-delivery machines, while others restrict it to only the historical fixed-level machines. So, it is THAT acronym--CPAP--that is now ill-defined, except to those people who have decided they know EXACTLY what it means!

Well, CPAP = continuous (fixed) pressure machines historically came first. And that's why they're the ones still called CPAP and nothing else but CPAP.

An interesting acronym that is growing both on forums like this and in the medical literature is xPAP where the "x" is a variable that stands for one of:

• C (fixed continuous positive air pressure)
  
  A (auto adjusting continuous positive air pressure)
  
  Bi or V (fixed bi-level continuous positive air pressure; there's one fixed pressure for inhale and a different fixed pressure for exhale)
  
  Auto Bi or Auto V (automatically adjusting bi-level continuous air pressure; the inhalation and exhalation pressures are allowed to vary, but they're still set separately from each other)
  
  ASV (auto-servo ventilation continuous positive air pressure; these machines can act like non-invasive ventilators and actually trigger inhalations when a person is failing to breathe on their own. They are mainly used to treat problems with central sleep apnea, where the problem is that the brain "forgets" to breathe rather than the airway is collapsed.)

But the context is also important: CPAP and xPAP are used interchangeably in some conversations (i.e. CPAP stands for any kind of PAP) and CPAP means "fixed continuous positive air pressure" in other contexts. When talking prescriptions, CPAP means "fixed continuous positive air pressure" and nothing else. If a doc wants something else, the something else must be explicitly specified.

To my situation...
last night, I turned off the EPR? (acronym deficiency again) --the thing that reduced pressure on exhale. AND, I upped the pressure from 12 to 14.

EPR = Exhalation Pressure Relief. The idea behind EPR is to make it easier for a person to exhale against the continuous positive air pressure by reducing the amount of continuous positive air pressure being delivered.

EPR is a patient comfort setting. If you don't like it, turn it off.

My thinking on the EPR is that, even though I had it set to 'fast,' that pressure did not return to high level until the machine detected start of an inhale.

That is indeed how the Resmed EPR system is designed to work. It's often referred to as a "poor man's BiPAP around here because essentially when EPR is turned on, the S9 machines are using one pressure for inhalation (the pressure setting) and another pressure for exhalation (the pressure setting minus the EPR setting).

So if the pressure is set to 12 and EPR = 3, then:

• Pressure on inhalation = 12
  
• Pressure on exhalation = 9 = 12-3
  

And the machine starts to increase the pressure back up towards 12 near the end of the exhalation and then bumps it all the way up to 12 by the peak of the inhalation.

But if you were 'apnea-ing' (especially a central), that signal would not even exist--and you would not get the pressure rise. I am thus running a machine essentially identical to those of decades ago, except that it collects data.

Not exactly.

All those years ago EPR did not yet exist. The old CPAP machines delivered the same pressure regardless of what was happening. If the pressure was set to 12, then the pressure was 12 when you were inhaling and it was 12 when you were exhaling and it was 12 when you were breathing fine on your own and it was 12 when you were having apnea after apnea after apnea.

Thing is, there's nothing a priori wrong with plain old CPAP = fixed continuous positive air pressure if the pressure is sufficiently high to keep the airway open all night long.

RESULT: AHI of 0.6--much better. I have not looked at the details yet.

What you are going to notice when you do look at the details is this:

The pressure will be at 14 all night long after the ramp period is over. It will be at 14 when you are breathing normally (almost the entire night). It will be at 14 during the random apnea/hypopnea events. It will be at 14 right after those events are over. And since you turned EPR = OFF, if you look at the pressure data stats in SleepyHead, both the Pressure and EPAP Pressure stats will be the same. And if you look at the Mask Pressure graph in Sleepy Head, it will be a fuzzy line right at 14 cm all night long.

The AHI is dramatically better simply because 14 cm of continuous positive air pressure is enough to keep your airway from collapsing and 12 cm of continuous positive air pressure on inhalation and 9 cm of continuous positive air pressure on exhalation is NOT enough to keep your airway from collapsing.

Because you changed both the EPR and the pressure setting at the same time, we don't really know if the problem with pressure = 12 and EPR = 3 was the exhalation pressure of 9 cm was too low or the inhalation pressure of 12 cm was too low or both were too low.

I have a question: what is the contraindication for using pressures higher than "needed?" In other words, if 12 would mostly solve your issues, what would be the problem (danger?) of running at 14? <<<Should this be a separate topic for the forum?

Short answer: In you can tolerate 14 cm in terms of comfort and you don't develop problems with pressure induced centrals, there is nothing wrong with using 14 cm instead of the titrated 12 cm.

Longer answer: Since last night went much better, you have evidence that your titration study may have resulted in an under titration: In other words, the night of the titration was not representative of what really goes on in your bed each night and you actually need a bit more pressure than 12 cm on a regular basis. Titration studies are NOT perfect, they really only provide a good starting "guess" as to what the real pressure needs are. Some people wind up being under titrated and some folks (like me) wind up being over titrated.

And the chances of developing pressure induced centrals is NOT very high; only about 10% of new PAPers ever have problems with pressure induced centrals, and for many of those PAPers, the problem will go away on its own once their body acclimates to xPAP therapy.

Hence, as long as your data continues to look good at 14 cm of pressure and you feel better (long term), then there's no good reason to NOT use 14 cm.

So I'd suggest that you leave the settings where they are for the next 4-7 days and then look at all the data as a whole. What I mean by that is to look at all the detailed data as a whole data set made up of 4-7 individual nights as well as the summary data from the entire period. Our OSA is not the same from night to night, and we all have the occasional really great nights and the occasional pretty bad (for us) nights. You don't want to get into the habit of increasing the pressure every time you have a bad night. But if you a week of bad nights, then you know that the current pressure may not be enough to manage the OSA.

[jcarerra]

That is great info. And you suggest exactly what I was intending--to get some more days with these settings, then check the data.

By the way, when I said " I am thus running a machine essentially identical to those of decades ago, except that it collects data," I meant " NOW THAT I HAVE TURNED OFF EPR, I am running a machine essentially identical to those of decades ago, except that it collects data."

i think that is correct as now the machine is constant, continuous, unchanging pressure--just like the old machines.

[robysue]

By the way, when I said " I am thus running a machine essentially identical to those of decades ago, except that it collects data," I meant " NOW THAT I HAVE TURNED OFF EPR, I am running a machine essentially identical to those of decades ago, except that it collects data."

Yep. That's correct. Sorry for misunderstanding what you meant.

i think that is correct as now the machine is constant, continuous, unchanging pressure--just like the old machines.

Yep, with EPR = OFF, the machine is blowing one constant pressure all night long just like the old machines.

[jcarerra]

Well, last night was not as good, using the same settings as the night before--which was great.

AHI went from 0.6 to 2.8. There was a series of 11 events between 4-5AM and 3 others scattered at other times.

See atch Details graph.
What are the blue dots on the axis?

[robysue]

What are the blue dots on the axis?

The blue dots are when the hyponeas were recorded.

For reasons that make no sense to me, ResScan reports the length of the apneas, but it doe not report the length of the hypopneas. It just shows them as little blue boxes

It's hard to make sense of the graph you attached because the time scale (x-axis) is missing.

Could you post a screen shot of these THREE graphs together:

The Wave Flow data itself (if you have it)
The Events table (what is shown)
The Leak Graph

Once we see all three of these graphs, it will be a bit easier to say something about what might be going on.

If I had to speculate: The two clusters might be REM related or they might be supine sleep related or they might be supine REM sleep.

As to what to do. You have two choices:

• Since this is only night 2 at your current settings, you can leave the settings where they are for several more days to see whether this particular night is just a "bad" night or whether night one was just a "good" night. In other words, you can gather a full week's worth of data at the current settings and then evaluate each of the nights individually AND the whole collection of data together.
  
• You can try increasing the pressure by another 0.5-1.0 cm

If it were me, I'd opt to stay at the same settings for a full week and then evaluate the whole larger set of data.

Rationale: Our sleep and our OSA is not the same from night to night. There will be some variability in the AHI from night to night and you might never succeed in eliminating all clusters every single night. The goal is to get to where your OSA is well under control on most nights. That means you want the AHI < 5.0 on all but the rarest night AND you want to have most nights free of nasty clusters of events. But if you have a bad OSA night with some serious clusters once or twice a month, sometimes the best thing is to simply not obsess about it. As a friend on another forum says, "Sometimes it's the aliens" meaning we all have a bad night every now and then.

The problem with increasing the pressure every time you have a bad night is that eventually you'll either reach the point where you are deeply uncomfortable because of the pressure OR the leaks will become significant OR you'll wind unnecessarily bumping up against the max pressure your machine allows. And while most people don't wind up having more events when the pressure is too high, some people do. Sometimes a "too high" pressure induces central apneas because the "too high" pressure causes you to blow off too much CO2. Sometimes a "too high" pressure simply causes unstable breathing because it increases the restlessness and discomfort. And what "too high" is depends strongly on the particular person. Some people need and do well with pressures close to 20cm. Others start having problems when the pressure is as low as 8 or 9 cm. It all depends on the particular person.

So there's a lot to be said for just being patient for a few days and seeing what seven nights worth of data at the current pressures look like.

But if you just can't force yourself to be that patient, then be cautious in how fast you increase the pressure. Only increase it 0.5 to 1.0 cm and try to give each new pressure setting at least 4 days so that your body has a chance to "settle in" with the new pressure.

[jcarerra]

Per request, atch is the Flow, events, and Leak graphs.
I set the time scale to cover the period with the cluster.

Aside: I have spent some time going thorough the entire Flow graph and discovered that my breathing pattern is often quite like that preceding the events, but do not quite meet the criteria and are not tagged. See 2nd atch.

Will go for a few more days and see if there is a pattern. But gosh, when drilling into these at expanded time scale to see "per breath" action...it can take hours to look through just one day's worth. And, at least for me, "what is going on"--how it looks--changes from minute to minute, or certainly over say a 5-10 minute period. It can be VERY different.

Oh, if you care about absolute time, add 5 hours to what is shown. I got tired of the data on the display disappearing at noon, so i set the clock back 5 hours to keep it until 5pm.

[robysue]

How long after going to bed did that first cluster start?

[jcarerra]

atch
remember add 5 for absolute time

[zonk]

I got tired of the data on the display disappearing at noon, so i set the clock back 5 hours to keep it until 5pm.

There is another menu where you can see the data after midday, until you take a nap in the afternoon or go to bed at nighttime. Press and hold both silver buttons for 3 sec, turn the dial to sleep report, push the dial to confirm and and scroll down, you can set it at the top to display the data for 1 day, week, month, etc. . You can also view the same setting as in the clinical menu but cannot make any changes from this menu

All explained in the clinical manual, available via Email
http://www.apneaboard.com/adjust-cpap-pr...tup-manual

S9 setup pictures and video http://www.apneaboard.com/resmed-s9-cpap-setup

As for the clusters, try sleep on your side, some people place a tennis ball inside a sock and attach it to the back of pyjama top and this prevent them from rolling on their backs
The AutoSet works on the principle, more pressure when needed like when rolling on your back or going in REM sleep and less pressure when not needed ... might be the solution to the problem but as always your doc is the best person to offer you such advice or otherwise

[jcarerra]

I learn too slowly! I knew about that menu--it just didn't occur to me that it gave the same data as the main info screen. I will set the time back to current.

I do sleep mostly on my sides, but can't guarantee am never on back when I am too asleep to know. Before CPAP, I was awake a lot changing positions; now much less. I am CONSCIOUSLY on back only when cannot drop off in a side position, then being on back seems to bring on the sleep feeling, but then something inside me says to go to a side position before the conk-out. Of course, if I am really asleep, I don't know what I might be doing.

Do you think a cluster is most likely in on back position?
Did the last image tell you anything?