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Resmed S9 user -- autoset or not
Let's re-invent the wheel for a moment?
What is the stated *goal* of a CPAP machine for OSA?

Improving the quality of sleep, decreasing the wake-up events during the sleep period, maintaining the blood O2 levels at acceptable levels = hopefully you waking up feeling better, and being more awake during your day.

Now, anything that achieves the above stated goals consistently (that's the key), works and is good.

I sleep better on a nasal mask with a slightly higher setting than the auto-set feature will set me too, but I leak through my lips like a sieve. If I go FFM, my AHI and leak rate are wonderful, but I wake often, and wake up tired.

SO - I am on auto-set, but set the minimum 1 number higher and left the top end wide open (random bad events get handled this way), I sleep like a baby on my 'Wisp'. AHI isn't as low, but still below 10 (which is great for me), and ya, my leak rate is all over the place - but more energy, more productive, more happy - so hello??? Which is best for me??

Same thing for you - I suspect, that if you looked at all the numbers on a report while on auto-set, you'd find that a large part of the night you are doing well around 9-10 or so, and that you have some events that need to go up to 12 or higher. Comfort dictates using a lower setting unless the machine sees you need higher pressure for an event. When on manual, they are sticking you on the number you need to handle *all* events, not just the bad ones...

Does this make sense?

FYI - Autoset all the way, but set your minimum to 8 to 10 so the machine will be in the right area all the time.
*I* am not a DOCTOR or any type of Health Care Professional.  My thoughts/suggestions/ideas are strictly only my opinions.

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I see a consensus emerging. Thanks for the advice. Very helpful. It's time to just do it, so I will. But first, I'll do some digging and decide what ramp speed and min and max air pressure numbers.
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If your titrated pressure was determined to be 12, then my suggestion would be to set the minimum to 8 and the maximum to 14. Then let it run for at least ten days. Watch the data, see how it goes. If after 5 days you see your 95% is regularly hitting 14, then of course raise it, but I'd not raise it sooner than that.

Too many things go into a night's sleep to let a single, or even two or three, night's worth of data determine the outcome. Yes, that's what a sleep lab does but they have a lot of other things going at the same time that also get figured into the equation. (although, really, that "titration" is only valid for those patients who actually sleep exactly as they would at home the entire test)

As for the ramp, that is a comfort feature. How long it lasts is based on how long it takes you to fall asleep. During the ramp, the machine is not collecting data. So if you set it for half an hour and you fall asleep in 10 minutes, yet you have events at 20 minutes, it is not recorded and the machine is not reacting to them.
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(05-20-2014, 07:55 PM)Island Sleeper Wrote: I see a consensus emerging. Thanks for the advice. Very helpful. It's time to just do it, so I will. But first, I'll do some digging and decide what ramp speed and min and max air pressure numbers.
I'll add to the consensus, with something you mentioned in your op. You hate the gassy bloated feeling you sometimes get on fixed cpap. I did too. Fought my doctor and the RT he sent me to on fixed pressure cpap for 3 months. Finally took the damn thing back, demanded a prescription for an autoset, and bought it myself from a different RT.
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Quote:You have already demonstrated the pillows mask can work well for you. The ffm will not solve the dry mouth thing if you simply breath through your mouth when using that mask. Many people feel they need the ffm because they are "mouth breathers." I know, because I was one. But with the chinstrap and a little practice there is no reason why the pillows mask, or at least a nasal mask would not work for most people. Even those whose nose doesn't stay clear all that well, like mine. The air pressure will establish the nasal airway and keep it open all night.

I too am a mouth breather who was given a FF and I woke up every night with a mouth that was so dry it tasted as if it was full of cotton.
I HATED IT and that alone could have ended my popping future.
I thought i would have to get a chin strap and try the pillow mask.

I tried my husbands unused Nasal and it was 100% the answer and no chin strap needed.
What I have noticed is that, at least on me, it sits just above my upper lip and because it sits there it somehow stops my mouth from opening up
Ive now been using this Nasal mask nightly for 2-3 weeks and not once have I opened my mouth.
It took a bit of getting used to over the first night for unlike a FF mask where you can open your mouth and breathe, its different with a nasal mask for as soon as you do open your mouth, because the air is going up your nose, you almost feel overwhelmed with too much air coming in both orifices at once so it took me a couple attempts the first night until I decided to try the Ramp feature and slowly went into it over 15 minutes.
Now I am used to it and i can start it on full and am fine....

I love this for I haven't found any need for the chin strap and I ALWAYS had my mouth open to breathe. In other words, I thought i would be the most unlikely person to ever get away with anything but a chin strap to keep my mouth shut so i have been very surprised by how well the nasal mask worked for me.
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My initial sleep study recommended a fixed pressure of 16 cm of water and 18 cm "when the patient can tolerate it". The diagnosis was mixed apnea, severe, with 60-70 episodes per hour. My sense is your pressures will vary over time, based on many different factors. My AHI have been extremely low for several years now. Recently, my AHI were around 6-10, over weeks. I added a humidifier that was recommended initially and set the ResMed to 3, the default setting for the durable equipment supplier. I used a fixed pressure CPAP initially and it was NOT very comfortable or effective. The ResMed S9 has been very good. My son just chose an S9 for himself and likes it a lot better than the old, very large, noisy autoset. I may end up increasing the lower pressure a bit. My airway seems to have a high resistance and the current low of 14 could be too low. I realize these are high values, but those are recommended by my initial sleep study in 2000 and by my current sleep doctor. I too do not use a ramp, just start up the machine automatically by breathing in the nasal mask and go straight to the low value. My experience to date is that the Autoset S9 and similar models of autopaps are better than a straight pressure CPAP and permit you a lower setting for routine use, with the ability of the machine to ramp up to higher values as needed. My vote is still for the autopap. I had to pay a bit more for that selection, but it appears to be a selection well made.
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The question was 'Is there any reason to prefer fixed air pressure over autoset'

The reason being, the autoset can increase pressure when most needed such as when you roll on your back or REM sleep which in both cases you need more pressure and less pressure at other times non-REM sleep stages

Another thing about the autoset, pre-empt apnea by increasing pressure in response to snoring and flow imitation which are sign of obstructive apnea and by doing that it accomplish two things at the same time:
1- prevent obstructive apnea from occurring
2- does not causes pressure increase unnecessary and prevent pressure induced central apnea

Plus the fact that the autoset is two machines in one, you can use it in autoset mode or CPAP mode
Nice to have something that you don,t need right now than need something that you don,t have ... or something like that Coffee

Edit: also price wise, the autoset cost some $40 more, better long term investment for small price difference
If your insurance paying for the machine, they pay by a billing code E0601 which is the same amount for a brick or the autoset ... they only care about compliance are met (not whether the machine is autoset or data capable)
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(05-19-2014, 02:55 PM)Island Sleeper Wrote: ISSUE: Is there any reason to prefer fixed air pressure over autoset on the following facts:

Sleep doc and myself are now at odds over the autoset function. It started life on a fixed pressure which I changed to autoset within a week, and five months ago on a followup, the doc took it off autoset and put it on a fixed setting of 12. Hate the sometimes bloated feeling in my gut, a non-factor on autoset.

Also since, the fixed pressure I now have dry mouth. On autoset where I also had very low AHI averages -- don't recall the number precisely, but around 1.2-1.5 -- I had no experience with dry mouth. Fixed pressure is like living with the Gobi desert, and bad as the discomfort is, I'm concerned with the side effect of dental caries.

I just had a follow up visit on the dry mouth and his best suggestion was to go to a full face mask, which is a non-starter. Tried that, realized I had the potential to become a serial killer, the amount of rage it generated in an otherwise pleasant disposition.

Between the doc and the techs from an associated sleep clinic, I get varying rationales for the fixed preference. One, it takes too long for the machine to ramp up on autoset after an apnea event, two, on autoset your brain is not being trained to adapt to the machine, ie, the machine is doing your thinking. I may have mis-described reason one, but the doctor is death on autoset and to my layman's mind and language, that seemed to be the essence of his objection. MY GP says other sleep docs are fine with autoset and there seems to be no consensus.

Adding to my lengthy preamble, which I hope will assist the smarter minds in responding and eliminate some of the guesswork, I use a chin strap, which I typically adjust once or more in the night. It is almost a reflex action which I do without fully wakening and am off again in a flash. I sleep on average seven hours but now wake up two to three times in the night to a dry mouth.

So, my preference is a return to autoset. Any thoughts?

Sounds like they're idiots or worse. All too common in the medical mafia.

The DME has a big incentive to scam you into a non-data capable manual CPAP. He gets paid the same, and it pays him the same money. The medical mafia has big incentive to not study data or use APAP because it generates more in lab $leep te$t$.

Even when they're not activly trying to screw you out of more money, there is a strong bias towards what generates the most cash. The system tends to rationalize whatever generates the most cash, even among practitioners who are trying to be honest.

It is something of a bad idea to simply give someone an auto, set it wide open and just let it run 4-20 cmH2O pressure. Most of the problems mentioned can be avoided or reduced by setting the machine to a narrower pressure range.

BTW, are you using EPR? That helps some people with aerophagia (bloating).
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(05-19-2014, 02:55 PM)Island Sleeper Wrote: ISSUE: Is there any reason to prefer fixed air pressure over autoset on the following facts:

Not really, as long as your autoset ranges are set appropriately.

But after reading about your issues, leaking is your problem IMO.

With auto and a lower starting pressure, you are likely leaking less. On a set 12, you are likely leaking more.

Fixing the leak (whichever route you go) is the most important issue IMO. If you have a good seal (with either just the nasal, nasal + chinstrap or FFM) and you have your humidifier set properly, you should be getting a dry mouth going from set pressure to autoset or vice versa.

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I used a fixed pressure machine at 18 cm for most of my Cpap life (8 years now). Just switched for an auto S9. Like getting behind the wheel of a very expensive import sports car compared to my old M-type. Quiet, smooth, the environmental controls are seemingly seamless (I never notice them, but I even have to check that the machine is doing its thing from time-to-time because it is so quiet and efficient), and I love the ability to dial in pressures for min/max. I'm still max at 18 and I can easily stand that without any exhale help, etc., but now I can also min at 14 and let the machine decide.

One of my thoughts on the issue was that a constant air supply at 18 cm would eventually train my diaphram or lungs to not do their own work. I'd rather be minimized when possible.
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