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New user - REM sleep apnea

I am first time poster. A bit of history - I was diagnosed with sleep apnea in the early 1990's and used a CPAP for a few years but got to a point where I would unconsciously rip the mask off after 2-3 hours so I stopped using it. I then tried UPPP surgery, a couple of different kinds of dental appliances and then gave up for a while. I had a sleep study a few months ago and just got a Resmed Aircurve 10 VAuto last week. I've been using the Dreamwear nasal pillow and have been pretty successful in keeping it on most of the night since I got it.

Here's a part of my sleep report that shows that my apnea seems to occur mostly in REM sleep (which was pointed out to me only recently):

RESPIRATORY ANALYSIS: (index = #/hr) Apnea/Hypopnea Index (AHI): 6.7
*AHI 4% or greater: 0.9

REM AHI: 24.0 
Non­Supine AHI: 5.4 
Supine AHI: 8.0
Respiratory Disturbance Index (RDI): 8.4 
REM RDI: 25.1 

In general, I am feeling really good after the first few nights of use. I used to feel extremely sleepy every afternoon and that hasn't been the case since I started using the machine. That having been said, I have a few questions/issues:

- I tried calling the technician that set me up to get some initial feedback on how the therapy was going and she informed me that they won't get the data for a couple of weeks since they had to register the device! I have attached a Sleepy Head screenshot from last night (I had to reduce the size of the jpeg by quite a bit to get it to upload. It would be much appreciated if some of the gurus in this group can provide some thoughts on it.

- The data shows that I have had some leakage issues. Last night was not bad (time over leak redline was 16%) but some of the earlier nights were much worse (35-40%). I don't think the mask itself is leaking (though I can't be sure). Is it possible that when the Auto setting raises the pressure, my mouth is being forced open and that is causing the leakage? The leakage seems better when I sleep on my back but given that my RDI is worse (from the sleep study) when I sleep on my back, is it better to sleep on my back to get a lower leak?

- I'm thinking of trying the Amara View FFM that someone else posted about since I am within the 30 days when I can change masks with no charge. Any thoughts on whether that might help?

- I see quite a few OA events. Should I be thinking of increasing the EPAP or IPAP pressure to reduce the OA events? Also, there seem to be more of them towards the end of the night. Is that consistent with REM sleep apnea?

- I also see quite a few CA events. Are those of any significance and is there a way to reduce them?



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G'day Vas, welcome to Apnea Board.

It looks like you're off to a reasonably good start, but there is quite a lot of room for improvement.

1. Leaks. I suspect the leak is indeed from your mouth, rather than from the mask itself. This may be overcome by training yourself to seal your mouth by placing the tip of your tongue behind your front teeth and creating a seal against your palate. (It works for many people - I can't do it). Alternatively (or in addition) you could try a chin strap which gently holds your jaw closed. This is the first and most important thing you need to work on, as the machine can't effectively treat you (or even diagnose an apnea) when the leak is over the red line.

2. Mask. The mask is the hardest part of this whole therapy. Every face is a different shape and size, and there are dozens of different makes and models on the market. I personally can't abide nasal or cushion-type masks and always use a full face, either F&P Simplus or Quattro Air. The Simplus seems to work for a lot of people so maybe give that a go. There are no guarantees here - you have to try it and see for yourself.

3. Apneas. On the face of it your numbers aren't bad, but bear in mind what I said above - the machine can't diagnose apneas if leaks are excessive. At this stage I'd work on the leak, and the apneas can follow.

4. Pressure. Your pressure is too low, as shown by the fact it goes immediately to maximum and stays there, even though you're in auto mode. In addition, your ramp time looks like it's set to the maximum (45 minutes) which is too long for effective treatment. However, these can wait until the leaks are sorted. Once we can see a chart with minimal leaks, then we'll know how the treatment is really going and whether it needs adjustment.
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To expand on what DeepBreathing said regarding pressure, you have a Vauto but it is handcuffed to fixed pressure by the prescription. The minimum EPAP pressure is unable to be raised, due to the IPAP maximum setting of 9.0 and a requirement to maintain pressure support of 4. The solution is to simply change IPAPmax to a considerably higher pressure like 14. The machine will only go as high as needed to suppress OA. So in Vauto mode, you will start at 9/5 and the machine will automatically increase pressure to 10/6, 11/7 etc as needed, and will use the 9/5 pressure as a baseline.

Overall, your summary looks pretty decent except for leaks. Resolving that, and giving the machine some room to respond to flow obstruction will resolve any residual issues.
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Thanks, DeepBreathing and SleepRider! That's very helpful!

I really like the Dreamwear but I don't know if I can train my mouth to stay closed :-)! I guess it will be even more difficult if the max EPAP is increased. I'm going to meet with my provider today to look at some alternative masks to see if that will reduce the leaks.  She's going to show me the Amara View which seems nice. I'll check out the Quattro Air and AirFit F10 too - they don't seem too bulky.

I'll reduce the ramp time. Is 30 min reasonable? Is there a way to have a longer ramp time when falling asleep initially and a shorter ramp time if I wake up in the middle of the night? I didn't find anything in the clinical menu.

I'll also increase the max EPAP once I get the mask stuff sorted out.

Thanks again! I feel like a new person the last week! I now wish I hadn't waited so long to check out the newer machines and masks after my aborted attempt at using CPAP many years ago :-(! Oh, well!

Funny story - we had a power outage yesterday. It turned out to be a shorted transformer and it will only be fixed today. We could have definitely slept at home but I told my wife that we had to go some place where there is power since I refuse to sleep without my CPAP any more :-)! She wasn't particularly thrilled with comments like you've done this for the past 20 years but I dug my heels and we landed up sleeping at a friend's place (with power)!

Speaking of which, any suggestions for battery packs that will work for camping and such like? How about for long airplane flights? On a recent flight to London, I saw a man sleeping with his CPAP.
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Your machine has an auto setting for ramp that can keep pressure low until sleep pattern breathing is detected.  I would use the auto setting. With pressure as low as you are using, a ramp is generally unnecessary.

To use your 24 volt machine with a battery, you must buy the Resmed battery power converters for the Airsense 10.  That is about $80 off the top.  Resmed makes a very expensive battery, but there are a lot of less expensive options out there.  With the converter, you are looking for a 12-volt power source.  The Poweradd Pilot Plus is a large lithium ion power bank intended for laptops that has shown good results with CPAP machines.  I believe air travel requires li-ion batteries to be less than 100 amp-hours, and this one is rated at 118.  It may or may not work for your intended use.  Also, you generally cannot run humidifier or hose heat on battery power.

Glad to hear you're feeling better with this new machine.
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Hi vas2000,
WELCOME! to the forum.!
It's good to hear that you got a newer machine so you can get better CPAP therapy.
Better luck to you this time on your CPAP journey.
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Thanks, Trish6hundred.

DeepBreathing and SleepRider, I tried out the Amara View mask and the results seem to have been rather disastrous from an AHI perspective. I got rid of the ramp and initially set the IPAP Max to 10 (from 9). When I woke up around 4 am, I noticed that the AHI was very high (around 17). I increased the IPAP Max to 14. I then had trouble falling asleep so I put in a ramp. Around then, I got the gurgling sound again (which I had encountered and overcame after the first day or two by increasing the hose temperature and putting the machine at a lower level) so I turned the humidification down to 0 and I think I managed to go back to sleep. Woke up around 6 with an extremely dry mouth.

The leakage numbers seem good compared to the leakage numbers with the Dreamwear mask. Any ideas about what is causing this high AHI? I am particularly puzzled with the high number of OA's after I increased the IPAP max to 14. With the leakage under control, is this a truer measure of the AHI which wasn't visible because of the leakage with the earlier mask?

I had tried the chin strap with the Dreamwear mask earlier but I wasn't sure that it worked for me. Given the large AHI with the Amara View, should I continue with it or go back to the Dreamwear+chin strap?

Thanks in advance!

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No attachment available. Sounds like the mask was not a great solution and the humidity was pretty disruptive.

Try using the links in my signature to learn how to post an image from Imgur. Attachments on the forum are very limited, and using a linked image instead will allow you to maintain a history.
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