frustrated with vpap auto

[me50]

I am frustrated with this new machine. I was prescribed it to help me tolerate the pressure (was 13 to 17 with cpap auto) and it was thought that vpap auto would help with that. but, my pressure is about the same with the vpap auto. I still have fragmented sleep.

I don't understand how the vpap auto works (they have it at 18/8) but I know that there doesn't seem to be any difference in the pressure and the fragmented sleep. This machine costs me a lot more than the cpap auto does and I don't mind paying for it if it helps with the issues I have been having for 3 years.

any suggestions would be helpful.

[robysue]

me50,

To help you understand how your new VPAP works and why it doesn't seem to provide as much relief from the pressure you were dealing with on the Autoset, we need to know the settings.

First: Are you running in Auto mode or fixed pressure mode?

Assuming you are running in Auto mode, what are the following settings:

min EPAP
max IPAP
PS

It might also be useful to know the TI min and TI max settings and the Cycle setting.

[me50]

me50,

To help you understand how your new VPAP works and why it doesn't seem to provide as much relief from the pressure you were dealing with on the Autoset, we need to know the settings.

First: Are you running in Auto mode or fixed pressure mode?

Assuming you are running in Auto mode, what are the following settings:

min EPAP
max IPAP
PS

It might also be useful to know the TI min and TI max settings and the Cycle setting.

EDIT: TI Max is 2.0; TI min is 0.3 and trigger and cycle is set to med. Min EPAP is 8 Max IPAP is 18 PS is 4 and I removed the attachment

[robysue]

TI Max is 2.0; TI min is 0.3 and trigger and cycle is set to med. Min EPAP is 8 Max IPAP is 18 PS is 4 and I removed the attachment

You said your settings on the AutoSet were 13-17. I'm assuming that you had EPR = 3 when you were using the Auto Set and that you're not using the ramp. So on the AutoSet, your pressures were:

OLD PRESSURES on the AUTOSET:
starting IPAP = min pressure = 13
starting EPAP = min pressure - EPR = 13 - 3 = 10cm
max IPAP = max pressure = 17
max EPAP = max pressure - EPR = 17-4

And at any point during the night,
10 <= EPAP <= 14
13 <= IPAP <= 17
and IPAP - EPAP = 3 all night long.


With the VPAP's settings these settings you have these pressures

NEW PRESSURES on the VPAP:
Starting EPAP = 8
Starting IPAP = min EPAP + PS = 8 + 4 = 12
Max IPAP = 18
Max EPAP = Max IPAP - PS = 18 - 4 = 14

And at any point during the night,
8 <= EPAP <= 14
14 <= IPAP <= 18
and IPAP - EPAP = 4 all night long.


So your starting IPAP on the VPAP is just one cm H20 below the starting IPAP on the Autoset and your starting EPAP is two cm H2O below the EPAP on the Autoset.

Your maximum pressures used to be IPAP = 17, EPAP = 14; they're now IPAP = 18, EPAP = 14 So there's actually a small increase in max IPAP and the max EPAP is the same.

In other words, your VPAP settings are virtually identical to your old AutoSet settings, with the main difference being that the pressure drops by 4cm instead of 3cm when you start to exhale. And my guess is that the difference in pressure settings is just not large enough for you to notice much difference.

You might report the problem to the sleep doc. It could be that a larger PS setting with might make the VPAP feel different (and more comfortable) than the AutoSet.

[me50]

on my cpap auto I did not use the EPR or the ramp.

On Jan 10, my median pressure was 12.6 95% was 16.1 and the max was 17.8 with 8.42 hours that night on the CPAP AUTO.

On Feb 1, my median IPAP pressure was 13.2, 95% was 16.3 and the max was 17.4 with 8.36 hours that night on VPAP AUTO. The EPAP pressure was median 9.2, 95% was 12.3 and the max was 13.4


So, to me, it looks like I am paying a lot of money each month to have about the same pressures as I had on CPAP auto and still having daytime tiredness and fragmented sleep. At least that is what it looks like to me. I will call the sleep doc tomorrow and see if I can email the data over for the time I have used the VPAP AUTO and let him know what I just posted here.

I don't know the cause of the fragmented sleep. I had it when I was on S9 Elite, S9 Auto and VPAP. I used to think a lot of it had to do with the leaks from the mask. In my last sleep study, I did wake up a lot but only for a few minutes.
I will go back and look at how often I woke up on all 3 machines and see if the fragmented sleep is less now than it was on the other 2 machines.

Anyway, I better get off of here too or I am going to be sleeping outside while all else, including the dogs, get the comfy beds.

Thanks robysue

[robysue]

I still have fragmented sleep.

Have you any ideas on what's causing the fragmented sleep?

You clearly believe that the fragmented sleep is somehow tied to your using the PAP machines. But the question is what do you think is causing the fragmented sleep?

Several things come to mind:

1) Something that is NOT directly related to using a PAP machine. There's a long list of things that can lead to fragmented sleep besides using a CPAP or untreated or undertreated OSA. In this case, tweaking the PAP settings is not likely to make much difference; you have to address the real cause of the fragmented sleep and fix that.

2) Changing pressures. You could be in the group of PAPers who do better on fixed pressure than on Auto. Some people are very sensitive to changes in pressure and they wake up or arouse when the machine starts increasing the pressure. These people often sleep sounder with a constant pressure (or a constant IPAP and constant EPAP presure) that is set to their 90% or 95% pressure readings.

3) Other comfort issues. What are they and how often do they affect you? Aerophagia can cause fragmented sleep and fragmented sleep can lead to more aerophagia. Leaks, even those not large enough to "count" as Large Leaks, can disturb some people enough to cause problems with fragmented sleep.

So what do you think might be causing the fragmented sleep?

I'm off to bed for the night, but I'll try to respond tomorrow.

[robysue]

on my cpap auto I did not use the EPR or the ramp

Ok, that means the OLD pressures were:

starting IPAP = starting EPAP = 13
max IPAP = max EPAP = 17.

So your IPAP is still about where it was, but the EPAP is lower since on the VPAP your EPAP is always between 8 and 14. My guess is that you're more sensitive to the way the IPAP feels and that's why you're not noticing much difference in the way the machine feels.

Does the change in pressure from IPAP to EPAP and back bother you in any way? Do you feel like you're having to change your breathing to match the machine's cycling back and forth?

And while I'm sure you've said in some previous thread, could you recap why the doc has switched you from the AutoSet to the VPAP? What specific problems was the doctor hoping would resolve with the switch in machine?

As I said before, I'm off to bed now.

[me50]

on my cpap auto I did not use the EPR or the ramp

you're more sensitive to the way the IPAP feels and that's why you're not noticing much difference in the way the machine feels.

IT ISN'T THE WAY THE MACHINE FEELS BUT THAT I STILL HAVE FRAGMENTED SLEEP, DAYTIME TIREDNESS, ETC.


Does the change in pressure from IPAP to EPAP and back bother you in any way?

NOT AS FAR AS I KNOW UNLESS THAT IS WHAT IS WAKING ME UP BUT BY LOOKING AT THE DATA, I DON'T THINK THAT IS THE PROBLEM


Do you feel like you're having to change your breathing to match the machine's cycling back and forth?

NO

And while I'm sure you've said in some previous thread, could you recap why the doc has switched you from the AutoSet to the VPAP? What specific problems was the doctor hoping would resolve with the switch in machine?

BECAUSE I WAS STILL HAVING FRAGMENTED SLEEP, TIRED DURING THE DAY, NO ENERGY SO I HAD A SLEEP STUDY ON A BILEVEL AND THEN I WAS GIVEN A BILEVEL. I DIDN'T SEE THE SLEEP DOC AFTER THE SLEEP STUDY (I CANCELLED MY APPOINTMENT)


As I said before, I'm off to bed now.

OK

[robysue]

If the data looks good---your AHI is consistently below 5 and your leaks are under control---and if you are NOT having any identifiable comfort issues such as aerophagia, nose sores, claustrophobia, etc., then chances are the fragmented sleep is being caused by something other than PAP issues and/or ineffectively treated OSA.

And PAP does not fix bad sleep; PAP only fixes sleep disordered breathing, regardless of whether it's CPAP, APAP, bi-level (VPAP-S) or auto bi-level So if there are any other causes for the bad sleep, those other causes have to be addressed before the overall quality of the sleep improves.

So fixing the fragmented sleep requires identifying and dealing with the cause of the fragmented sleep rather than simply tweaking the PAP settings.

So the first thing you need to do is to try to identify what other things might be causing the fragmented sleep. Questions to ponder:

1) What does your overall sleep hygiene look like?

2) How fragmented is the sleep? How many wakes do you typically have during the night? How long are you typically awake during the night? How much total sleep would you say you get on a typical night?

3) Do you have any medical conditions other than OSA that have fatigue or trouble sleeping as major symptoms? Thyroid problems often manifest themselves with daytime fatigue as the main symptom; anxiety and depression both can cause fragmented sleep; heart disease can affect the quality of sleep; and chronic pain (from any source) can lead to both daytime fatigue and fragmented sleep.

4) What medications do you take on a regular basis? Many medicines have "fatigue" and "problems sleeping" on the list of side affects.

5) What kinds of things are you willing to do in order to try to reduce the fragmentation in your current sleep patterns? In other words, would you prefer an approach that is largely non-drug based, but may require some significant, long term changes in your behavior (cognitive behavior therapy for insomnia) or would you prefer taking sleeping medication (such as Ambien) to see if that reduces the fragmentation or would you prefer a mixed approach? There is NO "correct" answer to this question that universally applies to all people. But you need to figure out what you are most comfortable with because the most effective way for you to try to deal with your fragmented sleep strongly depends on the answer to this question.

6) What are your expectations? In other words, what are you trying to achieve? Unrealistic expectations about what "decent" or "good enough" sleep is can lead to additional stress caused by worrying about the bad sleep, which can make the sleep get even worse. As hard as it sounds, sometimes it helps to simply not worry about the sleep for a few weeks.

You also write:

Does the change in pressure from IPAP to EPAP and back bother you in any way?

NOT AS FAR AS I KNOW UNLESS THAT IS WHAT IS WAKING ME UP BUT BY LOOKING AT THE DATA, I DON'T THINK THAT IS THE PROBLEM

Two comments:
1) Can you post some data from a very restless night? Post the flow rate (wave flow), the pressure line, and the leak line. Point out when you think the wakes occurred. It would also help to zoom in on one of the wakeful periods so that we can see about 5-10 minutes before the wake occurred, the wake itself, and (if possible) 5-10 minutes after you think you finally got back to sleep.

2) Have you ever tried fixed pressure(s)? You might do better on fixed pressure and experimenting with a fixed pressure setting is worthwhile if you have nothing else to try.

And while I'm sure you've said in some previous thread, could you recap why the doc has switched you from the AutoSet to the VPAP? What specific problems was the doctor hoping would resolve with the switch in machine?

BECAUSE I WAS STILL HAVING FRAGMENTED SLEEP, TIRED DURING THE DAY, NO ENERGY SO I HAD A SLEEP STUDY ON A BILEVEL AND THEN I WAS GIVEN A BILEVEL. I DIDN'T SEE THE SLEEP DOC AFTER THE SLEEP STUDY (I CANCELLED MY APPOINTMENT)

So "failure to resolve daytime symptoms" was what was used to justify the switch from APAP to bi-level?

How severe is the untreated OSA? And how long would you say you had OSA before it was diagnosed? The unfortunate and sad fact is that there are a small number of OSA patients for whom residual daytime sleepiness and fatigue remain issues even with effective PAP therapy and (seemingly) sound sleep. One theory is that the damage from the OSA is just too extensive in those patients to fully heal. Some docs are willing to prescribe an anti-narcolepsy drug like Provigil or Nuvigil to these patients---as long as the patient continues to use the PAP every night and the data from the PAP looks good. In other words, the Provigil/Nuvigil does not do anything to treat the OSA, but it can alleviate the remaining unresolved daytime symptoms. The downsides to using Provigil or Nuvigil include both cost (insurance may not pay for it) and the fact that these are pretty powerful drugs with a bunch of potentially serious side effects, so not everybody tolerates them very well.

[me50]

And PAP does not fix bad sleep; PAP only fixes sleep disordered breathing, regardless of whether it's CPAP, APAP, bi-level (VPAP-S) or auto bi-level So if there are any other causes for the bad sleep, those other causes have to be addressed before the overall quality of the sleep improves.

UNLESS THE FRAGMENTED SLEEP IS CAUSED BY NOT TOLERATING THE PRESSURE, LEAKS, ETC. DURING MY LAST TITRATION WITH THE VPAP, I DID WAKE UP A LOT BUT ONLY FOR A FEW MINUTES AND I WENT RIGHT BACK TO SLEEP AND FOR THE FIRST TIME IN ALL MY SLEEP STUDIES, I SLEPT MORE THAN AN HOUR AND A HALF SO IT SEEMED AS THOUGH VPAP WAS HELPING (YEP, I KNOW THAT IT WAS ONLY ONE NIGHT).

So fixing the fragmented sleep requires identifying and dealing with the cause of the fragmented sleep rather than simply tweaking the PAP settings.

So the first thing you need to do is to try to identify what other things might be causing the fragmented sleep. Questions to ponder:

1) What does your overall sleep hygiene look like?

SEEMS FINE

2) How fragmented is the sleep? How many wakes do you typically have during the night? How long are you typically awake during the night? How much total sleep would you say you get on a typical night?

3 TO 5 TIMES PER NIGHT (ONCE OR TWICE THERE WERE 8)

3) Do you have any medical conditions other than OSA that have fatigue or trouble sleeping as major symptoms? Thyroid problems often manifest themselves with daytime fatigue as the main symptom; anxiety and depression both can cause fragmented sleep; heart disease can affect the quality of sleep; and chronic pain (from any source) can lead to both daytime fatigue and fragmented sleep.

NOT THAT I KNOW OF. DEFINITELY NO DEPRESSION, NO THYROID, CHRONIC PAIN, HEART DISEASE THAT HAS BEEN DIAGNOSED. I HAD A LOT OF YEAR-END TESTS AND THE ONLY THING THAT I WAS TOLD WAS THAT MY VITAMIN D WAS WAY TOO LOW (12)

4) What medications do you take on a regular basis? Many medicines have "fatigue" and "problems sleeping" on the list of side affects.

NONE ON A REGULAR BASIS BUT AM CURRENTLY ON VITAMIN D3. I HAVE PRESCRIPTIONS FOR OTHER MEDICATION BUT HAVE NOT STARTED THEM B/C I AM WAITING ON THE DOC TO GIVE ME THE OKAY AFTER ALL OF MY YEAR-END TESTS. HIS EMPLOYEE TOLD ME THEY WERE OKAY BUT SHE ISN'T A NURSE, PA OR NP OR A DOC SO I AM WAITING TO HEAR FROM MY DOC. IF I DON'T BY FRIDAY, I WILL CALL AND MAKE AN APPOINTMENT TO DISCUSS IT WITH HIM.

5) What kinds of things are you willing to do in order to try to reduce the fragmentation in your current sleep patterns? In other words, would you prefer an approach that is largely non-drug based, but may require some significant, long term changes in your behavior (cognitive behavior therapy for insomnia) or would you prefer taking sleeping medication (such as Ambien) to see if that reduces the fragmentation or would you prefer a mixed approach? There is NO "correct" answer to this question that universally applies to all people. But you need to figure out what you are most comfortable with because the most effective way for you to try to deal with your fragmented sleep strongly depends on the answer to this question.

NON DRUG APPROACH AND I AM NOT SURE IF I HAVE INSOMNIA (NOBODY EVER SAID) BUT I DON'T THINK I HAVE NARCOLEPSY B/C I DON'T FALL ASLEEP DURING THE DAY BUT I DO GET TIRED AND WANT TO TAKE A NAP ON SOME DAYS AND I DO TAKE A NAP (MORE THAN 30 MINUTES)

6) What are your expectations? In other words, what are you trying to achieve? Unrealistic expectations about what "decent" or "good enough" sleep is can lead to additional stress caused by worrying about the bad sleep, which can make the sleep get even worse. As hard as it sounds, sometimes it helps to simply not worry about the sleep for a few weeks.

SLEEP FOR 7 OR 8 HOURS WITHOUT WAKING UP 5 TIMES PER NIGHT. I DON'T EVER REALLY WORRY ABOUT MY SLEEP. I JUST KNOW THAT THE VPAP ISN'T GIVING ME THE IMPROVEMENT THAT I AND THE DOC THOUGHT IT WAS GOING TO. IF MY MEDIAN, 95% AND MAX PRESSURE IS BASICALLY THE SAME WITH THE VPAP AS IT WAS WITH THE CPAP, THEN THERE IS MORE TO THE STORY ALONG WITH THE EXTRA EXPENSE FOR THE RESULTS TO BE THE SAME AS WITH CPAP. AS I SAID BEFORE, I DON'T MIND THE EXTRA COST IF IT IS THE ANSWER TO MY SITUATION. I DID NOTICE THAT I HAD SOME MA'S DURING MY TITRATION THAT I HAD NOT HAD ON PREVIOUS SLEEP STUDIES (YEP, I KNOW THAT IT IS ONLY ONE NIGHT).

You also write:

Does the change in pressure from IPAP to EPAP and back bother you in any way?

NOT AS FAR AS I KNOW UNLESS THAT IS WHAT IS WAKING ME UP BUT BY LOOKING AT THE DATA, I DON'T THINK THAT IS THE PROBLEM

Two comments:
1) Can you post some data from a very restless night? Post the flow rate (wave flow), the pressure line, and the leak line. Point out when you think the wakes occurred. It would also help to zoom in on one of the wakeful periods so that we can see about 5-10 minutes before the wake occurred, the wake itself, and (if possible) 5-10 minutes after you think you finally got back to sleep.

2) Have you ever tried fixed pressure(s)? You might do better on fixed pressure and experimenting with a fixed pressure setting is worthwhile if you have nothing else to try.

YEP, STARTED OUT WITH RESMED S9 ELITE, THEN S9 AUTO AND THEN S9 VPAP

And while I'm sure you've said in some previous thread, could you recap why the doc has switched you from the AutoSet to the VPAP? What specific problems was the doctor hoping would resolve with the switch in machine?

BECAUSE I WAS STILL HAVING FRAGMENTED SLEEP, TIRED DURING THE DAY, NO ENERGY SO I HAD A SLEEP STUDY ON A BILEVEL AND THEN I WAS GIVEN A BILEVEL. I DIDN'T SEE THE SLEEP DOC AFTER THE SLEEP STUDY (I CANCELLED MY APPOINTMENT)

So "failure to resolve daytime symptoms" was what was used to justify the switch from APAP to bi-level?

I DON'T KNOW AS I DID NOT TALK WITH MY DOCTOR. I DOUBT THAT IT WAS ONLY DAYTIME SYMPTOMS THOUGH. I BELIEVE IT WAS SEVERAL FACTORS AND THAT DURING MY VPAP TITRATION, I SLEPT FOR 4 OR 5 HOURS RATHER THAN THE NORMAL 1 1/2 AT THE OTHER SLEEP STUDIES AND I DID WAKE UP (MORE THAN I REALIZED AND REMEMBER) BUT I WENT RIGHT BACK TO SLEEP. SO, I AM NOT SURE WHAT CRITERIA THE DOCTOR SAW IN THE TITRATION RESULTS AND ME TELLING HIM WHAT ISSUES I WAS HAVING AND LOOKING AT MY LEAKS AND DETAILED DATA ON THE CPAP AUTO.
How severe is the untreated OSA?

COULDN'T TELL YOU AS THE LAST TWO STUDIES I HAD WAS FOR TITRATION ONLY. THE ONLY SLEEP STUDY I HAD WITHOUT A MACHINE WAS 3 YEARS AGO.

And how long would you say you had OSA before it was diagnosed?

SORRY, I HAVE NO CLUE

The unfortunate and sad fact is that there are a small number of OSA patients for whom residual daytime sleepiness and fatigue remain issues even with effective PAP therapy and (seemingly) sound sleep. One theory is that the damage from the OSA is just too extensive in those patients to fully heal. Some docs are willing to prescribe an anti-narcolepsy drug like Provigil or Nuvigil to these patients---as long as the patient continues to use the PAP every night and the data from the PAP looks good. In other words, the Provigil/Nuvigil does not do anything to treat the OSA, but it can alleviate the remaining unresolved daytime symptoms. The downsides to using Provigil or Nuvigil include both cost (insurance may not pay for it) and the fact that these are pretty powerful drugs with a bunch of potentially serious side effects, so not everybody tolerates them very well.

Thanks for your detailed response. appreciate it