Why High AHI using DreamStation vs AirSense 10??

[Walla Walla]

Fixit50,
It's going to come down to which one do you sleep better with. the Remed does react quicker from a lower pressure but than that causes discomfort for some. Others don't mind it. Once you get use to the pressure starting at a higher pressure is no biggie. So it comes down to what You like.

[ajack]

ajack,
Do you have a recommendation for setting the min and max pressures for my DreamStation auto?  I was thinking min of 12 maybe 13 and max of 20 (though it probably wont get there).  The idea of the higher minimum in my view is to allow the algorithm to increase to a needed pressure faster since it will have less change needed to obtain the needed pressure with the higher minimum.  The trade is when the higher minimum is not needed, it will hang out there possibly causing comfort issues.  Am I looking at this correctly?  I'm not certain I understand the theory of fine tuning the DreamStation or the importance of setting the minimum a specified distance from the 95% pressure.  
With the AirSense auto, 10 to 20 gave very low AHI.

The remed raises pressure quicker with the wrong settings for treatment.

I'm just repeating what I read. They use the median and 95% as a mark to set the min, max and fixed cpap pressure. It's more often right and gets into range, that may need a bit more tweaking. It's good enough to have as a signature.

I know this is more on a comparing 2 machine thread, but you need to stick with one thread for treatment advice, you can stay with the other one or start one with a clearer title 'help with adjustment' to get more people to look, you didn't get a reply to your other thread about your last charts posted.. http://www.apneaboard.com/forums/Thread-...eas?page=2

Your last AHI wasn't that bad, your 95% was 18cm. you have a choice, you can keep adjusting the min up to stay just under your median or set the min 2cm below the 95%, both will work. (was I talking with you on one of your threads, about moving to BPAP? If not it was someone with similar chart readings)
 https://imgur.com/a/j72rZ

[heov]

I own both aircurve 10 and DS bipap auto. I get higher AHI with DS. I really wanted to make the DS work because it feels sooo comfortable when awake. But ill go weeks with resmed, try the DS for a night and regret it. So I do think it truly is not as effective as resmed.

[Sleeprider]

While the analysis is interesting, you choice should be obvious. I will speculate that the reason events are so high on a Respironics is mostly to do with the Flex pressure relief rather than the EPR. It is apparently triggering incomplete breath cycles as the pressure relief only occurs very briefly, and in proportion to your respiratory flow, while EPR actually is giving you a full 2-cm pressure relief on each breath. I think you might tolerate a BiPAP Auto machine, better than a CPAP. The dramatic difference really isn't debatable. You get relatively poor results on the Dreamstation, and if you look closely at the respiration flow rate charts I think you will see the difference or irregularity resulting from the different pressure relief. It is even visible on the large full-night scale.

[Fixit50]

My thanks to Walla Walla, ajack, heov, and Sleeprider for the recent help.  

1. OK, I’m a little confused.  First off both ajack and Sleeprider think I need a BiPAP.  This is great except I don’t understand the reasons why I’d benefit. I thought the whole reason for the BiPAP was to permit higher pressures while allowing for more pressure support which is needed with the higher pressures.  If one is not having events at 20cm then what can the BiPAP do that an APAP cannot?   
   
2. Also, Sleeprider thinks the DreamStation FLEX pressure relief is playing a role in the higher AHI seen here:  https://imgur.com/a/LysSZ  I thought the purpose of pressure relief was for comfort during expiration, not for therapy.  I’ve even heard that the decreased pressure from pressure relief can make AHI scores worse. Sleeprider mentions that the FLEX relief is triggering incomplete breath cycles and this can be seen on the Flow Rate at the above link.  Can you tell me what you are seeing?  I don’t know what to look for but would love to understand this!    
   
3. Also, if I were to try to get my insurance to approve an expensive BiPAP, can I expect them to do so when my AHI scores with the ResMed APAP are well below 5?  I’m not sure what their BiPAP approval criteria is, but I’d expect them to say “you don’t have a problem!  Call me when your AHI scores are too high!!”  
   

Many thanks for the continued help!

[Fixit50]

... One more thing:  In the second screen shot found in the DS data here https://imgur.com/a/LysSZ you can see an 11 minute session where my breathing rate went to 42!  The waveform looks healthy save for the astronomical breathing rate!  This has happened before though with not not such a good looking waveform so I suspected the poor waveform fooled the breath rate detection.  Not so in this case.  Also, later that same night my wife got up and later told me I was breathing very fast and shallow.  I guess that nails it.  Something is going on that causes me to breath rapidly at night but with no apneas.  What does this mean??

[ajack]

The chart shows the DS is a cpap and not bpap?

I would start with a check list of things you have done and do. To see of you can get a cpap working for you.
*first pick one machine..( I personally think the resmed for now, this was your resmed chart https://imgur.com/a/j72rZ )

with your current DS chart.
*The flag chart looks clustered, positional obstructions? Have you used a cervical collar yet
* if you are using the DS raise the min to 12
* turn the flex off
* start the ramp at 8 if you really have to have it, I'd turn it off.

It may have been a very active 11 minutes of REM? It can be funny stuff, that in itself isn't the worst thing to happen. You have the rest of the night that needs work.

I think periodic breathing is the term, if you want to fix that you may need at least a bpap and maybe one the more advanced bilevel systems. Do you have good health ins and covered your out of pocket? I'd want a lab test

[Sleeprider]

I didn't intend to make this confusing.  Your resultsare far better with the Resmed machine.  Ditch the Philips Respiroinics machine because this would suck!




With the Resmed machine, you record far fewer events, but things are far from perfect.  Your session on 11/6 looks pretty good, but there is a lot of unbalanced breathing shown in the flow rate.  The session on 11/8 is even more erratic, including extremely rapid respiration, which we examined on the Respironics machine and found consisted of extremely flow-limited inhales. I'm not sure if we looked closeup at your Resmed flow limited breaths,but I suspect they look like the ones as shown in the Respironics example 3-graphs below:










We saw similar respiration in another member recently (Hojo http://www.apneaboard.com/forums/Thread-...mendations ).  This was referred back to his medical team for evaluation, and they elevated his case to more informed specialists and scheduled a BiPAP titration.  The analysis of why this repiratory pattern occurs in you or Hojo is beyond my expertise, and I can speculate whether this may respond to bilevel or if it might need something like ASV to stabilize.  In theory, the pressure support of bilevel should stabilize the inspriation of those very flow-limited breaths, allowing a rapid complete and normal respiration.  I don't pretend to understand this odd respiratory pattern, its causes or its cures, but you should probably find an interested and engaged medical team to help you resolve it.

[Fixit50]

Sorry for the delay in getting back.  Ajack wrote:
“The chart shows the DS is a cpap and not bpap?
I would start with a check list of things you have done and do. To see of you can get a cpap working for you.
*first pick one machine..( I personally think the resmed for now, this was your resmed chart https://imgur.com/a/j72rZ )
with your current DS chart.
*The flag chart looks clustered, positional obstructions? Have you used a cervical collar yet
* if you are using the DS raise the min to 12
* turn the flex off
* start the ramp at 8 if you really have to have it, I'd turn it off.
It may have been a very active 11 minutes of REM? It can be funny stuff, that in itself isn't the worst thing to happen. You have the rest of the night that needs work.
I think periodic breathing is the term, if you want to fix that you may need at least a bpap and maybe one the more advanced bilevel systems. Do you have good health ins and covered your out of pocket? I'd want a lab test”

Ajack, Thanks for your response and suggestions.  I understand the Sleepyhead chart shows cpap.  I think it means auto cpap.  The machine was in auto mode from 10-20 with ramp start at 4.  Yes, that link was to a ResMed night.  I used the ResMed on the 10th with good results AHI < 1 and used the DS on the 11th with the revised settings you mentioned except I bumped the min pressure to 13 and the ramp start to 7.  Turned off flex which surprisingly did not bother me maybe because pressures never got too high.  The AHI went down to 5.9 and I felt very good all day.  The machine functioned very close to CPAP staying at 13cm 95.5% of the time and never got higher than 15cm which of course didn’t last long.
Have not yet gotten a collar but plan to experiment with something, probably a new pillow first.
So, 42 breaths per minute is not a problem?  Wow, surprised to hear this!  The DME folks said REM can result in poor breathing waveforms but these waveforms are present at times for nearly half of a 4-hour session.  I have a hard time believing I spend that much time in REM!    
Why did you mention periodic breathing?  That is not flagged on the data.
Also, I had an in-lab sleep test 4 months ago.  I have the data they gave me but no waveforms.  They found that cpap at 13 cmH2O worked well over a 1.5-hour period and stamped it a prescription.  Then I got the autoset.  Personally, I think you can learn as much about needed CPAP pressures from an overnight sleep test as you can about your blood pressure from a single measurement.  
Anyway, I returned the DS yesterday and now my machine is the AirSense 10.  I don’t care for the harsh sounding exhale noise it makes but I suspect the algorithm allows for more optimal tweeking.  To be sure I’m not certain if any of that will translate into improved symptoms or not; it was a close call.  

Sleeprider, Thanks for your response and information and for the Hojo link.  I read that over.  Interesting and relavent.  You said:
“I'm not sure if we looked closeup at your Resmed flow limited breaths,but I suspect they look like the ones as shown in the Respironics example 3-graphs below:”
A good example of the jagged looking waveforms on the AirSense that concern me is seen in the last chart here: https://imgur.com/a/52Upo
There doesn’t seem to be a lot of flow limit activity but more typically I see this kind of waveform accompanied by a lot of activity in the Flow Limit graph.  I agree its probably best to get my concern to my sleep doctor and see if I can get him interested enough to think about it.  My fear is that he may not take it very seriously since the AHI score is so good.  I plan to put the issue before him nevertheless and see what comes of it.  I’ll also experiment with a new pillow and etc.  I’ve already used a chin strap in conjunction with my FFM a few weeks ago and it makes a big difference!  Basically, it solves the problem.  Flow limit activity goes down along with pressure and the jagged and rapid breathing practically disappears.  Oh, and another thing.  I don’t like chin straps! Maybe an oral snore appliance…

[Greggory]

One clue is that I seem to get more "events" scored while awake wearing the Dreamstation than I do with the Resmed.  Thus I think the Dreamstation probably has more false positives.

I have a Dreamstation Bi-PAP autoSV. I've been taking infrared video and also wearing a Alice PDx home sleep study monitor in order to be able to evaluate scoring. It's very clear that the Dreamstation is scoring many events when I'm awake re-positioning myself in bed - everything from Snoring to Flow Limitations to Hypopneas to Central Apneas.