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[CPAP] Still feeling bad - What does data show?
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StillHoping Offline

Members

Posts: 10
Joined: Mar 2016

Machine: ResMed AirSense 10 Elite
Mask Type: Full face mask
Mask Make & Model: Philips Respironics Amara View
Humidifier: (integrated)
CPAP Pressure: 10.2
CPAP Software: SleepyHead

Other Comments: Started PR System One Auto-Trial: Sept. 2015. Switched to CPAP Jan. 1, 2016

Sex: Male
Location: USA

Post: #11
RE: Still feeling bad - What does data show?
Answers are very much appreciated. Thank you all.

Mine was a home sleep test. The printout shows (picking some perhaps relevant ones):

Apnea/Hypopnea index - 13.5/h
Apnea Index - 3.2/h
Hypopnea index - 10.2/h
Flow Limitation index - 19.0%
Longest Apnea - 27s
Longest Hypopnea - 57s

There is a bar chart also, with colors for OA, "Apnea Mixed", "Apnea Central", Hypopnea Obstructive, and Hypopnea. The color of the last two are identical. When looking at the chart I see mostly "Apnea Mixed" and/or HO/H. There are a few Central bars too (like 10 of them on the chart). Given that there were only 4 hours of sleep data (the rest of the 8 hours I couldn't sleep and was reading) and the chart is not clear (to me at all), I'm afraid there's not much to conclude about any percentage of CA's. Dr's diag was "mild OSA".
04-13-2016 10:52 AM
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robysue Online
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Posts: 1,247
Joined: Oct 2013

Machine: PR Dreamstation BiPAP Auto
Mask Type: Nasal pillows
Mask Make & Model: Swift FX
Humidifier: PR Dreamstation humidfier
CPAP Pressure: min EPAP = 4; max IPAP = 9;
CPAP Software: SleepyHead EncoreBasic EncorePro

Other Comments: Papping since September 2010

Sex: Female
Location: Buffalo, NY

Post: #12
RE: Still feeling bad - What does data show?
StillHoping,

The problem seems to be that your machine is recording a fair number of CAs. And CAs don't usually disappear by increasing the pressure and increased pressure can make them worse.

Have the CAs been in the machine recorded data ever since you started CPAP/APAP? Or are they new?

About 10-15% of new PAPers do develop some problems with CAs after starting therapy. But for most of these people, the CAs will disappear on their own after a few weeks to a couple of months of therapy. In other words, for most of these people, the CAs disappear after the body fully adjusts to PAP therapy and the brain is no longer struggling to figure out how to maintain the correct CO2 level in the presence of the slightly pressurized air.

But you've been PAPing for quite a while. So if the CAs were present right from the start, it would be reasonable to assume that if they were going to disappear on their own, they probably would be substantially lower than they currently are. So it's good that you are planning on seeing the sleep doc in the near future to address what's going on.

Quote:What are the basic differences between these machines (with some technical info)? And which machine type might be the right option (or best next step) to help my apneas?
...
1. PR REMstar Pro C-Flex+ System One. This is the machine I was started with last fall in "Auto-Trial" mode, the purpose they clearly told me was to ascertain the optimal pressure to use when I was switched to CPAP (which occurred after 3 mo's).
The Auto-Trial mode for the System One pro is a "time-limited" APAP. There's a maximum length of time the machine can be run in APAP mode and after that it switches (or is switched) to straight CPAP mode. When the machine is in Auto-Trial mode, it is running as a full fledged APAP. The only difference between the System One PRO and the System One AUTO is that the Auto can run in APAP mode for as long as you own the machine.

Both the System One PRO and the System One AUTO are typically used to treat plain old OSA. Both have a Flex system to provide exhalation relief. Sometimes the Flex setting can have an affect on a person's tendency to develop CAs. How the Flex does this varies from person to person. So if Flex is set to 2 or 3 and you're getting a fair number of CAs, you can try turning Flex down or off. Conversely if Flex is off or set to 1 or 2, you can try turning the Flex up.

Quote:2. "BiPAP" - At the last visit the tech suggested this type of machine would help CA's. So I'll be asking about this.
Technically speaking BiPAPs are not specifically designed to treat CAs. But they're substantially cheaper than the ASV machines. Many insurance companies will require an unsuccessful trial on BiPAP or BiPAP auto before moving a patient to an ASV machine.

A simple BiPAP (or Resmed VPAP) runs in what is called "S" mode. It increases the pressure to the IPAP pressure at the beginning of each inhalation and decreases it to the EPAP pressure at the beginning of each exhalation. The IPAP and EPAP pressures are fixed and the difference between IPAP and EPAP can be set to be anywhere between 1cm and 6-8cm (or more). The most typical IPAP-EPAP spread is about 3-5cm. An Auto BiPAP allows the IPAP and EPAP pressures to vary in response to events. PR Auto BiPAPs allow the IPAP and EPAP pressures to vary independently of each other; Resmed Auto VPAPs increase and decrease the IPAP and EPAP together so the IPAP-EPAP difference remains constant.

Some people who have problems with pressure-induced CAs do find that their CAs disappear when switched to BiPAP/VPAP. The pressure relief created by the drop to EPAP can make it easier to fully exhale and that in turn can make it easier for the body to properly maintain the nighttime CO2 levels where they need to be to trigger nice regular sleep breathing. And it's this fact that underlies the usual insurance company's insistence on a BiPAP/VPAP trial before authorizing a switch to ASV.


Quote:3. APAP - For example the AirSense 10 AutoSet (as I've read).
The Resmed AirSense 10 AutoSet is just the newest Resmed version of the PR System One Auto CPAP. The newest PR APAP is the PR DreamStation Auto CPAP by the way.

In theory the AirSense 10 AutoSet can't do anything in Auto mode that your old PR System One Pro couldn't do when it was running in Auto-Trial mode except, of course, run in Auto mode for an unlimited amount of time.

In other words, all an APAP does is allow you to run in Auto mode for the entire time you own the machine. Or switch to fixed pressure mode and run in CPAP mode if you want. So APAPs are a bit more flexible that straight CPAPs.

But it's also important to understand that there are some differences between the Auto algorithms for the AirSense 10 AutoSet and the PR Auto CPAPs. Which is best for your particular situation can be a very tough question to answer since most people don't have a chance to do a head-to-head comparison. The presumption made by most sleep docs is that both algorithms ought to be about equally effective (in terms of treating OSA) and equally comfortable. They also assume that most patients probably won't be able to tell any difference between the two machines.

Quote:4. ASV
ASV machines are very expensive and they tend to be used to treat primary central sleep apnea problems as well as treating complex sleep apnea in patients who continue to have significant numbers of pressure induced CAs after several weeks or months of CPAP, APAP, BiPAP (VPAP), and/or Auto BiPAP(VPAP) therapy. In other words, they're typically used when all else fails.

ASV machines can (and do) act as noninvasive ventilators in a way that CPAPs, APAPs, and BiPAPs do not. An ASV machine can attempt to "trigger" an inhalation when you have not inhaled on your own for a specified amount of time. An ASV machine can also monitor the tidal volume of your breathing and it may also trigger inhalations if your breathing becomes too shallow to maintain a proper CO2 level. The ASV "triggers" an inhalation by drastically increasing just the IPAP at fixed time intervals when no inhalation (or an insufficient inhalation) occurs. The BiPAP (VPAP) machines do not increase the pressure to IPAP until an inhalation is detected.

ASV machines are often used to treat CSR since CSR can result in long chains of CAs, which occur at the nadir of the breathing cycle.

Quote:I've also learned that insurance may only want to move to APAP if CPAP isn't working. Maybe they'll keep me on the CPAP.
The insurance code for CPAP and APAP machines is the same thing. So if your doc were to write a script for APAP, there's a good chance the DME would just swap the current CPAP out for an APAP from the same manufacturer. (How your copays would work depend on your insurance company, the DME, and whether the machine is sold on a "rent to own" contract or was sold outright.)

Most insurance companies will want some kind of documented evidence for switching a patient from CPAP/APAP to bilevel (BiPAP or VPAP). What that documented evidence is may depend on the insurance company. The insurance company or the sleep doc may insist on a new titration study before switching a patient from CPAP/APAP to bilevel.

In my case, my sleep doc wrote a one page memo saying the following:
  • I had tried CPAP and APAP (same Resmed S9 AutoSet) at several different pressures,
  • I had tried more than one mask style,
  • I was still experiencing severe aerophagia in spite of the changes to therapy,
  • I was using the machine at least 4 hours every night with low machine reported AHIs,
  • and I was unable to function in the daytime due to sleep deprivation in spite of using the machine every night as prescribed.

After that, the insurance company authorized a bilevel titration study and after that study, they were willing to pay for the bilevel machine that I now use.

Questions about SleepyHead?
See my Guide to SleepyHead
04-13-2016 12:55 PM
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StillHoping Offline

Members

Posts: 10
Joined: Mar 2016

Machine: ResMed AirSense 10 Elite
Mask Type: Full face mask
Mask Make & Model: Philips Respironics Amara View
Humidifier: (integrated)
CPAP Pressure: 10.2
CPAP Software: SleepyHead

Other Comments: Started PR System One Auto-Trial: Sept. 2015. Switched to CPAP Jan. 1, 2016

Sex: Male
Location: USA

Post: #13
RE: Still feeling bad - What does data show?
Thanks much. I have all the data from my AirSense 10 Elite since I started Dec. 29th so I've gathered some of that here. However before I get to the CA data of interest... there's a big mystery going on because the AHI numbers prior to March 1st disagree by a lot with what I was seeing every day on my myair (resmed dot com)/Dashboard (the machine uploads Events/hr, Usage hours, Mask Seal and Mask On/Off data to the site).

The AHI numbers I saw on myAir before Mar. 1st were consistently 3 - 5. However the SH numbers in that same time period show values of 0.5 - 1.5 !! Also, the detailed data in the Overview tab of SH is all blank (missing) prior to Mar. 1st.

Here's a timeline in terms of what I definitely saw via the MyAir dashboard:
Jan. 1st -> Feb. 29th: An AHI of between 3 and 5 every day.
Mar. 1st -> April 4th: An AHI of between 3 and 5 every day.
April 5th -> Today : An AHI of between 5 and 12 every day (gone up a lot now).

Corresponding to that same timeline here's what I see in the SH data (after import from card):
Jan. 1st -> Feb. 29th: An AHI of between 0.5 and 1.5 every day.
Mar. 1st -> April 4th: An AHI of between 3 and 5 every day (numbers now approx. same as myAir).
April 5th -> Today : An AHI of between 5 and 12 every day.

Something weird happened on Mar. 1st!

Corresponding to that same timeline here's some ideas also on changes:
Jan. 1st -> Feb. 29th: Pressure was increased (by clinic) from 9.2 to 10.2 Jan.30th.
Mar. 1st -> April 4th: Press. increased to 10.4 on Mar 1st (3 days later I had them put it back to 10.2)
April 5th -> Today: I lowered the EPR to 2 for 2 days on April 5th, then returned it to original value of 3.

Summary: Was the much lower AHI value before Mar. 1 some data import error or limitation of SH related to my card config? If so why hasn't it happened again? I've imported several more times on a different computer, but it's only the data before Mar. 1st. Also note that Feb. 29th was a leap day. But why would the AHI numbers get chopped down (subtracting about 3 for each day).

Anyway, about the CA values over this strange data:
Jan. 1st -> Feb. 29th: Typical CA/OA/H = 0.64/0.9/0.14 (CA = 37%)
Mar. 1st -> April 4th: Typical CA/OA/H = 3.0/0.6/0.7 (CA = 68%)
April 5th -> Today: Typical CA/OA/H = 3.0/0.9/0.7 (CA = 65%)

What is interesting is the amount of OA has stayed about the same (numbers are approx and vary). But both the CA and H apneas jumped all at once starting Mar. 1. Mar. 1st does correlate with when the pressure was increased (yet again, by the clinic) to 10.4. But I called back to say it felt uncomfortable and my AHI was rising 3 days later... so I had them return it to 10.2.

But if the jump in CA and H on Mar. 1st is related to the pressure increase, why is all the SH detailed data (e.g. the charts) missing (the stats info is avail)? It's like something was changed on the machine. Maybe since I mentioned to the tech that I would be using SH they enabled something in the machine at the same time when she updated the card to incr. the pressure. And that changed manifested as different values for the earlier data. That's my guess.

The other interesting thing is that it seems like since I fiddled with EPR (from 3 to 2), the AHI is getting worse (and yes, feel like napping now, irritable, etc). Maybe it's unrelated, so many variables.
04-13-2016 06:12 PM
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StillHoping Offline

Members

Posts: 10
Joined: Mar 2016

Machine: ResMed AirSense 10 Elite
Mask Type: Full face mask
Mask Make & Model: Philips Respironics Amara View
Humidifier: (integrated)
CPAP Pressure: 10.2
CPAP Software: SleepyHead

Other Comments: Started PR System One Auto-Trial: Sept. 2015. Switched to CPAP Jan. 1, 2016

Sex: Male
Location: USA

Post: #14
RE: Still feeling bad - What does data show?
The jump on Mar. 1st of the SH numbers is a SH glitch I believe because I saw the Dr. this morning and the glitch didn't show up in the Resmed s/w charts. And the apparent incr. in CA's percentage-wise may be due to other factors besides pressure. At any rate, we scheduled a sleep study (over a month from now) to see what's going on with the high amount of CA's. There will be a lot of things to check at that time. Many factors were mentioned that will be examined. Appreciate all the replies, the info everyone provided is really really helpful. I will be sure to relate back later what we find out or the outcome later.
04-14-2016 02:22 PM
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