[Equipment] PR System One replaced with Löwenstein Prisma 25S

[tolnaiz]

My Father is using a PR System One since 2013. We thought it's time to replace it for the well known reasons (philips recall, 5+ years of usage).
I tried to ask for a Resmed Aircurve 10, but the doctor strongly recommended the Löwenstein Prisma 25S instead, so we had to choose that.

On the old machine he had a steady 7-10 AHI with the following settings:
Min EPAP 10.0 Max IPAP 22.0 PS 3.0-6.0 with Bi-Flex 3
EPAP is decreased to 6 by the doctor last year, but since it caused a lot more apneas, we went back to EPAP of 10.

With the new machine he prescibed the following settings: min and max EEPAP is 6 on trilevel with PDIFF 2-8.
This machine has a little unusual terms, but according to this video (https://www.youtube.com/watch?v=OfuJekqlNL8)
roughly EEPAP is EPAP and PDIFF is PS + Bi-Flex in normal Bi-Level terms. If I'm correct.
Interestingly, it seems like if min and max EEPAP is the same, then PDIFF will not change from the minimum level either. It stays on fixed level of pressures.

The best setting so far is EEPAP between 7-8 and PDIFF 2-5 and the doctor's fixed setting.
This is approaching the old machine's 7-10 AHI if I'm not count central hypopneas (I don't even know why prismaTS calculates it separately)
So far, any attempts to increase EEPAP or PS lead to higher AHIs, more unstable breathing, mouthbreathing, and I think some burping (aerophagia?).

Now I'm not sure how should I compare the results with the old machine.
Should I just look at AHI without CH and accept that he's fine with the lower pressure levels and the new machine is just more strict about hypopneas?
Or is there a room for improvement?
In this case, can you please make some advice what adjustments would be worth to try?

If I just stand by him while he is sleeping, I think his breathing is worse than with the old machine.
If I ask him he always says he slept fine. 
He has several other medical conditions (high BMI, CKD, strokes, diabetes, neuropathia, had colon cancer)


I'm attaching some screenshots from the old machine's OSCAR report and the new machines PrismaTS reports.

https://drive.google.com/drive/folders/1...sp=sharing

Thanks

[Sleeprider]

Generally an increase in hypopnea requires an increase in minimum pressure support. I would avoid creating more discomfort by raising EPAP at this time, but would raise PDIFF 2-5 to 3-5 and observe if this helps. I'm partial to the Resmed Aircurve 10 Vauto because we get such good detailed data and have great control over inspiratory timing and the trigger and cycle sensitivity.

[tolnaiz]

Sadly this machine does not allow changing those settings in autoS mode, but it allows in S mode (fixed bilevel).
Because the best setting so far is already close to fixed level, maybe it would worth trying S mode?

There is ramp in, trigger in and ti/t setting in S mode.

[tolnaiz]

As Kappa suggested here http://www.apneaboard.com/forums/Thread-...nsupported

We tried CPAP mode last night and it resulted an AHI level of 7 which is a lot better than last year's average.

SpO2 level is quite stable too.

Leaking however is worse than with BiPAP.

I guess we will see a few more nights with the old machine, before trying Prisma in APAP.

What do you think?

[sawinglogz]

Turning off bi-level does seem to help the centrals immensely. It didn't seem to have much effect on obstructive.

You might also look at reducing the flex level, which can sometimes trigger centrals as well (it's currently at its max setting).

Looking at the remaining obstructive apneas and hypopneas, it looks to me like you might want to bump up the minimum pressure a little (maybe to 13?) and turn off the ramp (if he can tolerate it).

[kappa]

I agree with Sawing. As you said, the SpO2 numbers appear a lot better as well - up from a min/median of 83%/94% to 90%/97% and much more stable.

Leaks don't seem that different between the 2 nights. Wouldn't expect a difference based on PS changes...?

[tolnaiz]

One more night with the same setting. Tonight I will raise the pressure a little.

[sawinglogz]

Two periods of significant leak (surprisingly not marked by the machine as large leak) where his SpO2 crashed.

I’m not sure what to make of those. Low respiratory drive perhaps?

[tolnaiz]

Here is yesterday with 11H2Ocm. I think he did better with 10.

I'm thinking going back to 10 with lower EPR. 

If it will work, then we switch to prisma APAP std mode with Pmin 10 Pmax 16 softPAP 2.

According to this http://www.apneaboard.com/forums/Thread-...vs-dynamic

Std mode changes pressure much less rapidly.

[tolnaiz]

We had not much success with reduced EPR. Screenshot attached. It seems like minEPAP 10 with Bi-flex 3 gave the best results. 

He slept with prisma yesterday. This machine is increasing the pressure quite fast even at standard mode, so I decided to limit Pmax to 12 for now. 
I was afrait that it will keep the pressure high and mouth leaking will ruin the whole night.
I also rolled a towel to put it under his chin.

So we went with Pmin 10 Pmax 12 and softPAP 2 which is actually means 2,5 H2Ocm EPR.
Im attaching both prismaTS screenshot and the work in progress OSCAR version.
This was the best night with prisma so far although still definitely worse than with system one.

What would you suggest to try with prisma?

Thanks.