Sierra

It sounds like you may have a central apnea issue like I have. What I found with the machine in auto, is that it seemed to elevate pressure in response to hypopnea that was probably central in nature, and not obstructive. More pressure caused more central apnea, so it just got worse and worse. At first I limited maximum pressure and then a year ago or so, I switched the machine into fixed pressure CPAP mode. Now I use EPR during ramp only, and then go to a fixed 11 cm all night.

I use the A10 machine and my wife still has the S9. The A10 has a significant improvement over the S9, and that is the AutoRamp feature. While it is called a ramp it really is a "Hold" not a ramp. It holds the pressure at the ramp start pressure until the machine detects you are asleep. Then, it ramps up the pressure fairly quickly to your minimum pressure, if the start pressure is lower than the minimum pressure. If minimum pressure is the same as the ramp start pressure nothing really changes when you go to sleep, other than you turn control of pressure over to the machine. Here is the way I recommend setting up the A10 for maximum comfort (I will assume you have a minimum and maximum of 7 and 14 cm).

Go to the Comfort section of the Clinical Menu and then set this way:

• Ramp Time - Auto
• Start Pressure - 7 cm
• EPR - On
• EPR Type - Ramp Only
• EPR Level - 3 cm

When set this way you will get 7 cm on inhale and 4 cm on exhale, and that does not change until the machine decides you are asleep. Most find it comfortable to have a lower exhale pressure while they are still awake. However reducing exhale pressure while you are sleeping can make the machine less effective, so like you do, I want EPR off when I am sleeping. Like I said AutoRamp is a hold, not really a ramp. The machine gives you up to 30 minutes to fall asleep, and if you have not it will go into auto mode based on 30 minutes elapsed time. If you have a minimum of 7 and the Ramp Start is also 7 there will be no change in inhale pressure when you go into auto mode, but the exhale pressure reduction due to the EPR will stop. I never ever notice when it makes the switch over, and I very seldom time out on the 30 minutes. Here is an example of what my going to sleep looks like in SleepyHead. I have switched to a fixed CPAP mode on my machine and I have that set at 11 cm. I like a little higher start pressure than 7 cm and use 9 cm as start pressure. If you look at the mask pressure graph you will see the machine pulsing up and down on inhale and exhale between 9 cm and 6 cm, and then when I go to sleep the reduction on exhale ends, and the pressure ramps up to 11 cm in my case. I was suffering from a cold this particular night and some of the mask pressure spikes you see are me coughing into the mask. Also I got up for a P, and you can see how the AutoRamp feature works again until I fall asleep. It looks like I fell asleep after about 8 minutes each time.

I tried the AirFit F20, but gave up on it. Couldn't stop the leaks and get comfortable with it. I still have it, and had a look at the venting system. It is a ring of holes in the part which snaps to the mask itself. Possibly the holes are plugged? The manual shows cleaning them with a toothbrush. There is also an AirTouch F20 mask which is a little different. Not sure if the parts are interchangeable and you may have gotten the wrong parts, and somehow the vent part gets blocked? In any case if you disconnect the mask hose from the CPAP hose and then put the mask on while you totally block the end of the mask hose with your hand, you should still be able to breathe in and out freely through the mask vents. It is a matter of trying to figure out what is blocking the vents, if that is the issue. Perhaps try the old parts to see if you have the same issue, and if they match the new parts?

What type of mask are you using? All masks have a vent system to allow air to continuously bleed out to keep the air in the mask fresh. The same vent also allows you to exhale. I would check that vent for plugging. Most masks have some kind of a flow diffusing system to minimize the noise and air flow velocity. Some are more resistant to plugging than others.

I don't believe in the SoClean ozone machines, and the CPAP manufacturers do not recommend them either. I clean my mask, hose, and water reservoir, ideally once a week, first thing in the morning. I use full strength vinegar first, and then add some Dawn dish soap next, and then do a good final rinse with tap water. I then hang them to dry on the shower head in the bathroom to drip dry during the day. Some apparently use the CPAP pre-warm function to circulate air through the mask and hose, but I have never bothered with that. I do normally use the pre-warm feature before I go to bed each night though.

Do you think you were asleep? It certainly does not look like a classic central apnea event. The machine starts testing after 4 seconds, and there is still no airflow after 10 seconds, it declares it an event. It looks like you may have been drifting off to sleep, but woke up. Some call this sleep-wake noise, where breathing gets irregular when the body is deciding whether or not to actually go to sleep. Most do not consider this apnea.

Here is an example of what you are looking for in SleepyHead. In the screenshot below there are three events in succession. The first one is classed as a CA event or clear airway or central apnea. The next two are classed as OA or obstructive apnea. If you look at the mask pressure during the event you will see the trace paint a band of up and down pressure fluctuation. That is the machine increasing and decreasing flow quite rapidly to determine how the pressure responds. If the airway is clear the pressure does not fluctuate as much up and down. If the airway is blocked the blue band that is painted by the mask pressure is wider (up and down). It is not a huge difference, but there is a difference if you look closely.

Also be aware that during the ramp or autoramp the flagging of events is suppressed. So if you want the best picture of what is happening when you are going to sleep, you may want to try turning the ramp off. Then events will be flagged right from the time you turn the machine on. Once you find out what is actually happening then there is probably a strategy with the ramp and ramp pressure that could minimize it.

It should have Rutoramp and ramp only EPR then.

However I would focus on determining exactly what type of event is occurring at sleep onset. If you zoom in on the SleepyHead data you should be able to determine what the cause is.

One issue with a CPAP where the mask does not fit well, can be leaks blowing into your eyes. I had that issue with a full face mask, and it not only caused dry eye, but also kept waking me up. I gave up on a full face mask and went to the P10 nasal pillow mask.

I would suggest you continue asking about the test results. You may be into an abnormal situation, but normally the more pressure that is used, the more obstructive apnea is reduced. However, the more pressure that is used often causes more and more central apnea. So the critical question would be as to what specifically caused the test to fail. Too much obstructive apnea, or too much central apnea?

The fact that you are being referred to a pulmonologist suggests that central apnea is an issue. Underlying heart issues can be aggravated by pressure and result in more central apnea.

If it turns out that central apnea is the major issue, then a BiPAP is unlikely to be a good solution. In that case an ASV type machine may be needed. There are some specific heart function tests that have to be done before an ASV machine can be prescribed. Here is a link to some information about the ResMed 10 ASV.