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Issues moving from CPAP to APAP
#1
First post after much reading of your wonderful forum!

My name is Bill (sorry for the long post),
 
I have consistently used two Fischer Paykel CPAP machines (latest ICON) for 8 years set at my original 2009 prescription of 7cmH2O with humidity. When my ICON died I bought a ResMed AirSense10 AutoSet with heat/humidity on Amazon instead of facing the medical gauntlet (Tricare and now Medicare). I have come to feel dependent on my machines for a good night’s sleep and yet I have suspected for some time that I was being under treated at the original fixed setting. Problem is that I overestimated my ability even with the forum help to adjust the machine to meet my needs.  
 
I figured as an “experienced” user that an APAP was a great idea even if I had to pay for it on my own. After all, there never has been any real support, anyway. I basically set the ResMed 10 to auto (EPR off and I didn't know about the clinical menus until problems arose) and left the default range of 4-20 figuring it would tell me what my treatment levels should be. I quickly realized that having NO technical support was not good. Your forum is a godsend. Thank you. So here is my experience and current problem:
 
Night 1: I jumped right in, but ended up with little sleep, bloating, discomfort from pressure, and a badly leaking mask (full face Forma I have worn for years). SleepyHead said AHI good at <1, 95% level was 13, but Leak above ResMed redline was horrible at 49%.
 
Night 2: I carefully adjusted the mask and left the settings alone and had the worst night I can remember. Encountered the runaway air problem that created such bad problems that SleepHead numbers don’t even make sense (95% at 17.66). Biggest problem was severe bloating.
 
Night 3: Took your advice to someone else and just set the machine at +/- 3 from my CPAP setting of 7 (or 4-10). Results felt good in most ways: AHI zero and Leak .3%. But I was troubled by having new machine that was not really setup to function as an APAP, since 95% was pegged at 10.
 
Night 4: Still thinking that I should be trying to get the “proper” APAP treatment, I shifted to 6-12. Results surprised me because sleep was bad, bloating was bad, and leaking was now about 10%, 95% was 11.98, apnea was controlled, but I had a bad night’s sleep.
 
Night 5: I threw caution to the wind and reset pressure at 7-14 to match my understanding of the SleepyHead data and your typical advice. Pressure line was contained between the 7 (abt 7.8) and the 14 (95% at 13.22) lines. My mask was so tight it was uncomfortable to the max, but I had only a 1.5% leak rate at the higher settings (for me). Two problems arose: 1) AHI rose some and 2) serious bloating became almost unbearable. Not comfortable at all on many levels even though the graphs are the best if I didn’t tell you how bad the experience was.
 
Night 6: Because of the severe bloating and overall discomfort I backed off and set smaller range around a level higher than my old prescription (7-11). Not the worst night, but still had significant bloating and 95% was pegged at 11.
 
I of course should have jumped into the forum for help sooner, but I really thought I could hone in on the right answer using SleepyHead and reading your past advice. So here are my questions now based on my efforts so far:
 
1)  Should I just go back to a flat CPAP 7 and see what SleepHead says or go back to my best “all things considered so far” setting of 4-10 and adjust from there?
2)  Either way, I feel like I have to fix the bloating problem as a priority. Do you have ideas on that based on how this evolved this week? I have taken Nexium for years, but the GERD relationship with CPAP and bloating has only became a problem with the new APAP driven higher pressures. My understanding is that the bloating problem is not “Aerophaquia,” but rather “gastric insufflation.” Is that helpful to finding a solution besides just reducing APAP pressures?
3)  And finally the real question is should I even chase “correct” therapeutic treatment levels taking advantage of the APAP and SleepHead as long as I can keep AHI below 5 at lower pressure levels WHILE avoiding the severe bloating for as long as possible?  
 
I know from reading your forum that balancing everything can be a challenge, but thanks for being there for me and so many other people.
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#2
If your old machine was indeed not putting out the pressure it was supposed to, it could feel as if you are getting too much air with the "overflow" going to your stomach.

My advice is to pick a setting and leave it there. You have made so many changes in the past few days, there's no way to tell what the problem is. Too many variables.

Put it on 6 and 12 then leave it. With the bloating, raise the head of your bed just a touch. With the mask, overtight is making it worse. Sit up with the mask and machine on and adjust the mask's straps. Lay down and readjust. If it is too tight, it breaks the seal it was designed to have.
PaulaO2
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#3
If you know your ICON was resolving apnea at a better rate, then fixed pressure can help some people get better results. There are a number of things you can consider to increase your comfort, and you should also reflect on their impact on therapy. What I am reading from your results is that you have aerophagia when pressure goes above a certain level. That can be minimized somewhat by using the EPR feature. Exhale pressure relief provides from 0 (off) to 3 cm of pressure relief during exhale. This often helps those with air ingestion problems avoid taking in air. The lower exhale pressure can affect obstructive and central apnea events, so it's something you should be informed about.

It appears your former CPAP pressure may have been too low. Since you didn't have data, you can see what a fixed pressure of 7.0 does, by simply setting the machine in CPAP mode and setting the pressure to 7.0. My guess is you may be disappointed with the results, but it's good baseline information to have in your hip pocket.

Since your pressure tends to move to 14 cm, and that causes bloating, I think setting the machine in autoset mode, with a minimum of 7 and maximum of 12 with EPR at 2, might work. If aerophagia occurs, reduce maximum pressure by 1.0 until it is acceptable. When someone comes here with aerophagia, I think it is important that you know, the first objective of this therapy is a good night of sleep. In your case that means balancing AHI with comfort, or limiting the pressure that causes air to be forced past the lower esophageal sphincter (LES).

If you want to post some data, we can try to thread that needle a little more precisely. The links in my signature show how to organize SleepyHead data, how to host images on Imgur and post them to this forum. There is a handy link to a mask fitting article by one of our members you might also find useful. Welcome, good luck.
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#4
and post the data!!!  Paula's 6-12 is good for now 
You knew that was coming.

The breakdown of the AHI is important.  This is in the Events Graph.  I'd also add the Flow Limit Graph and the Snore graph.

When you post, add a space to the IMGUR url until you have 4 posts.

Expect us to suggest a change to this range once we see the data.
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#5
A little confused. Between the choices back of 6-12, 7-12 w/EPR2, and 7, I think the flat 7 is best for tonight to at least try and find some comfort and get some baseline data for the level I have been on for a long time. I may even need a few nights there just to settle down.

The problem with a max 12 is that it is definitely too high for me, which is why I tried 7-11 last night and even that was intolerable. We can talk more about combining EPR in a day or so. You may have noticed several days ago I went to 6-12 myself thinking that would be the answer, but I had horrible bloating (I don't actually "feel as if [I am] getting too much air" or swallowing air. I just wake up blown up like a balloon with pain and normal bodily functions messed up when I get up. Pretty scary actually. During the second 4-20 night when I had little/no mask leaking, I had more gas in one single day than ever in my entire life by at least double).

By the way the ResMed AirSense10 AutoSet screen has shown two green smiley faces every day with only one red for mask for leaking that first night since the start of all this. MyAir has averaged 96 since the first night (which was 78 because of the 49% mask and less than seven hours sleep). I figure these tools are pretty much worthless for any kind of real analysis (for me for sure). Thank you so much for putting me on to SleepyHead! I know my problems seem strange since my pressures are not even high, but even the flat 7-level treatment has had the effect of ending atrial-fibrillation and associated palpitations/fluttering symptoms since I went on the CPAP 8 years ago. I can go back to that if I must.

Thank you so much for your help. I consider this forum a real blessing.
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#6
I was thinking that if Night 3 worked so well, why not try that setting for a week?

But I'm a newbie and I know the others who posted already have good info for you.

You'll get this figured out!

And whether you have an Auto but use it for fixed, who cares? You have *options* as you move forward over the next several years, so it's all ok. :thumbsup:
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#7
I have had a gas problem also. It is at a balance now for me by slowly working with all the settings.

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#8
I was suggesting settings that would provide us with the most data with the knowledge that after seeing the data it would be changed to something more tolerable.  It was to see how your body reacted to the CPAP at various settings quickly.
The typical self titrating settings are auto at 4-20.  We like a narrower set.  In any case please post data, your impression and feelings of how you sleep are important, but to give you the best advice the data makes the difference.   it is not unlikely that we will see something that you are missing in what you may feel is unrelated.

Please post some data.
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#9
Thanks everyone. So here is what happened when I went to the flat 7.

Learned that SleepyHead does not give me the normal graphs when not in APAP mode and only limited data.

Even so SleepyHead says AHI was 0.03 (MyAir says 0.40 events per hour - not sure why they are different). Since this seems really good especially under the circumstances combined with the best night's sleep in a week, I'll take it. Still had some bloating, but not too bad. I think this is lingering because I am still recovering from the "high" pressures (for me at least) that seemed to stress the lower esophageal sphincter (LES).

So it seems to me that I need a narrow range at a lower level for a while - how about 5-9 (i.e. 7 +/- 2)? As noted originally the 4-10 (7 +/- 3) was best (before last night), but it was a restless night even though the AHI was perfect at zero. Either would at least get me the graphs back while staying treated. I am not sure about EPR or how I would ever get to the 7-14 range that the machine takes me to when it is left to function as it is designed. I intend to see a specialist on the LES issue after what we have discovered. Does anyone know what type of doctor specializes in the LES in the context of APAP treatment?

Please recommend new range so I can get the graphs back as well as anything else that comes to mind.

  
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#10
I believe you can put it in Auto mode, but have the min 7 and the max 7... and then you'll get your graphs.
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