Sierra

Based on your comments I am not totally sure you have the machine set up correctly. When you enable the SmartStart option it should just start with a smooth even pressure buildup when you put the mask on. It may take a breath or two, but it should just start. Then you will see the pressure ramp up to your minimum slowly. Keep in mind that the minimum pressure setting is independent from the ramp start pressure. If you want to lower them below the 7 cm I suggested you have to adjust them both down. The ramp start cannot be lower than the minimum pressure. When you start the machine it should go to either the ramp start pressure if it is lower than the minimum, or if they are the same then to that pressure.

The machine tries to maintain a set pressure, so if you turn the machine on without you having the mask on, then there will be a big rush of air as it is trying to build up pressure with no resistance to flow. I just use the SmartStart option and I just have to put the mask on to start the machine for the night. When I take it off, I usually push the machine off button just before I take the mask off. It stops that big rush of air. However if you just take the mask off there will be a big rush of air and then the machine will stop from the SmartStart control. The machine is set to maintain a small air flow after you shut it off to let it cool down and purge moisture. You should see a little icon on the screen indicating it is cooling down.

As far as maximum pressure of 12 or 10, that setting should not have a big impact on the pressure you are getting as it will only go up to that pressure if it detects apnea or hypopnea. It is simply a maximum, and I would expect in your case it will not go that high. If you wake up in the night and press the round button it should display your current pressure that it is controlling to in automatic. However, SleepyHead is the best way to see what goes on during the night.

I believe when you do the mask fit test it goes to the maximum set pressure for the test. However, in auto it will not go there unless it has to.

With the EPR set to ramp only and set at 3 cm. It will always be trying to reduce the exhale pressure by 3 cm. However the machine will not go below 4 cm no matter how you set it. So if you have a ramp start of 5 cm, it will reduce to 4, and with a ramp start of 6 it reduces to 4 and so on. Only if you have a ramp start higher will the exhale pressure be above 4 cm. For example I use a ramp start of 9 cm because that is what feels right to me. During the ramp I get 9 cm on inhale and 6 cm on exhale. As far as it feeling hard to exhale that is something you get used to. After my ramp is over the machine goes to 11 cm on inhale and exhale. I have no difficulty exhaling against that pressure or even higher. Some people exhale against as much as 25 cm on a bipap machine. '

Hope that helps some. One other feature I may not have mentioned that can improve comfort some is the prewarming of the humidifier. You can turn it on manually with the menu item that I recall is just below the mask fit option. It warms up automatically and there will be a small air flow during the warming. It takes about 15 minutes to fully warm up, and then it sits on hold. I usually turn it on when I first start getting prepared for bed, and then use the machine regardless of whether or not it is fully warmed up or not. The machine will still start as soon as you put the mask on and take a couple of breaths.

Any other questions, or if I missed something just ask. You will find SleepyHead very enlightening as to how the machine is performing. All of those pressure changes when going through the ramp can be seen in SleepyHead. If you zoom in using the arrow keys you can see each breath and how much the pressure is going up and down during the ramp. It is a good way to confirm that the machine is performing as you expect it to. An most important it will show what the machine does with pressure after you go to sleep, and whether or not you are having any events. Here is what my machine mask pressure looks like during ramp. This is with a ramp start of 9 cm, EPR of 3, and then a pressure of 11 cm when the ramp ends.

Sometimes posts get hung up in the spam filter. Other than that, not sure what could be going on. I think you will find the hydrocortisone better than just Vaseline. It should not be used for an extended period of time though - just until you get over the irritation.

Which specific mask do you have? I have used the ResMed AirFit P10 and the F&P Brevida. The Brevida I found gave me a little more nose irritation, but I think I could have gotten used to it, if I had stuck with it. The P10 fit me better, but initially did give me some nose irritation. I had a fit pack with the Small, Medium, and Large inserts. I found the Medium sealed better but went too far into my nose and caused more irritation. I think the P10 works best if it sits more on the entry to the nostrils rather than right in them, and I now use the Large size. The other thing that I find helps initially is to put a little bit of over the counter 1% hydrocortisone cream on the irritated part of the nose in the morning. I found that after a week or so of using the hydrocortisone the irritation went away. And if it is an adjustable mask, make sure it is not too tight.

Mask

When a mask has not been fitted for you by a technician, the normal way to buy the P10 is with a fit pack which includes a small, medium, and large cushion sizes. You just try them and use the one that fits the best. You want it to fit on your nostrils not right into them. It will seal better if you use the size that goes right in, but I found that can irritate your nose. I use the Large size. When you look at the mask and are going to put it on, you have it oriented correctly when you can see the L and R for left and right nostrils. In the middle will be the marking for the mask size; S, M, L. The P10 is pretty much non adjustable although there are some goofy clips that can be used to adjust to some degree. I would just use it as is for a start. SleepyHead will give you a good indication of how well the mask is sealing. You should not feel any air leaking out where the mask seals to your nostrils. However there is a mesh screen on both sides of the front. Air will flow out of there continuously as a purge flow and also more when you exhale.

Machine

Believe them when they say not to move the machine with water in it. While nothing real serious will happen, you most likely will dump water into the hose and that will cause a bit of excitement when it blows into your nose. My machine generally stays put, and I have never pulled it off the bed side table. Ideally you want the machine about even with your head or even a bit higher. If you pull on the hose most often what will happen is the mask hose will separate from the machine hose. I did it last night. In a pinch you can put your machine on the floor if you have enough hose. A chair would do fine too if the seat is level. Everyone seems to do the hose differently. I have a headboard on our bed that I can loop the heated hose through to the middle of the bed and then down the center of the bed. The other option is to run it behind the pillow to the center of the bed. It comes down to about my waist. From there the mask hose goes up to my nose. When I sleep on my right side facing the middle the hose just lays in the middle in a loop. When I sleep on my back it just comes up over my chest. And, when I roll over to face the outside of the bed on my left side it loops over my tummy and comes up the left side on the bed and to my nose.

Settings

Settings are best suggested by your sleep clinic, but I know you are on your own, so I will make some conservative recommendations to start with. To answer your questions, yes the machine knows when you are exhaling. When it is in EPR mode it reduces the pressure when you have inhaled fully and start to exhale. It increases the pressure again when you have fully exhaled and start to inhale. It is in effect blowing continuously as those purge vents on the front will always have air coming out to prevent CO2 from building up in the mask housing. So here are the setting in the order they appear on the machine. You probably know it, but you press and hold the front Home key at the same time as the top round set knob for about 5 seconds to get into the Clinical menu. When there you rotate the knob on top to scroll down, and press it to make selections. These are the starting settings I would suggest for the maximum comfort using conservative pressures.

• Mode: AutoSet for Her
• Min Pressure: 7 cm
• Max Pressure: 12 cm
• Mask: Pillows
• Ramp Time: Auto
• Start Pressure: 7 cm
• EPR: On
• EPR Type: Ramp Only
• EPR Level: 3 cm
• Climate Control: Should default to Auto with Heated Hose connected
• Tube Temp: 27 C or 81 F
• Essentials: Plus
• SmartStart: On (This starts the machine as soon as you put the mask on and start breathing, and stops it when you disconnect the hose)

Make sure you set the Date and Time correctly or you will have trouble changing it later. If you press the Home key and then select return to User Menu, you will be out and the machine will be functional.

SD Card

The standard card is 4 GB and will probably hold most of a year's data before it starts to overwrite. If you regularly download to SleepyHead you will have a permanent record of readings on your PC.

Hope that helps. If you post your SleepyHead chart I can make some suggestions as to how you could optimize the settings further. If you have any other questions, just ask...

I am not confused about central apnea. I have it, and get more experience every day.

My first choice would be a ResMed AirSense 10 AutoSet For Her. The For Her version includes an extra algorithm that is suitable for lower obstructive apnea and higher hypopnea. It is only a setup option, so you can use it, or use the standard algorithm. The Dreamstation would be a second choice. About the only feature it lacks is the ability to use EPR on ramp only, like the ResMed does.

The really poor choice would be the Fisher and Paykel machine. It does not distinguish between centrals and obstructive apnea, and increases pressure to both. The ResMed and Dreamstation ignore centrals, but report them.

On a search I found this link to a manual which may help if it is the correct one.

Pulse Oximiter CMS-50F Manual

About all I can say is that a CPAP machine is not a cure. It just uses pressure to keep the airway open when it is in use. Obviously as soon as you take it off the benefit goes away.

Just make sure the APAP can distinguish between obstructive and central apnea, and report on the proportion of each.

I have never bothered to sign up for MyAir because I think the reporting is not useful for the reasons you give. All it gets is the basic compliance data that is sent wirelessly to the MyAir website. Instead I use SleepyHead to view the detailed data. You can get a little more detailed report from the machine itself if you go into the Clinical Menu and set the Essentials to Plus. But, SleepyHead is still much better.