Sierra

The changes you made to max and min pressure have helped. The next thing I would do is turn off the Flex. If you look at the Pressure chart, the red line shows pressure on inhale (IPAP). The green line is kind of the pressure on exhale (EPAP). As you move your cursor across the screen, the numbers above the pressure graph will show the pressure at that specific time. So, if you match the cursor up with an event you can see at what pressure it occurs at. The issue with leaving Flex turned on is that events can occur on exhale as well as inhale. The lower pressure can create events. My experience is that it is best to turn Flex off on a DreamStation. This may reduce your event frequency, and possibly your pressure too.

The other point of significance in this chart and the other one from Jan 7, are the green highlighted areas which Respironics calls periodic breathing. ResMed flags something similar as Cheyne Stokes Respiration (CSR). This is what CSR looks like on a close up breath by breath basis.

What you should do is put your cursor over one of those areas where there is green highlighting and CA events flagged. Then left click repeatedly or use the up arrow to expand the scale to see the breath by breath detail. If looks like the CSR image above this is something to discuss with your GP, and/or cardiologist. It could be heart issues, or heart medication, other medication, etc. You do not happen to live at a higher elevation? That can aggravate it too. If you can post a zoomed in screen of the periodic breathing area including the central events, I can give you my thoughts on how it compares to what I am seeing in my own charts.

I have seen a very small amount of CSR flagged in my charts, but over time I see a very small amount. The last time I saw it was over two months ago. With a ResMed the CPAP stats page in SleepyHead includes the % of CSR.

As far as your settings go the only change I would make now would be to turn Flex off. Future opportunities may be to lower the max pressure below 18 cm, but I wouldn't jump into that until you see what setting flex to zero or shutting it off does.

What this chart shows is that your 95% pressure is equal to your maximum pressure of 14 cm. You are also getting many of your events, mainly obstructive, but a significant number of CA events too at maximum pressure. In short it is showing you would benefit from a higher maximum pressure. I have never found the AHI graph because of the way it records to be really helpful. The Event flags show just as well where the events are occurring. Instead of the AHI graph you may want to bring up the Minute Ventilation graph if DreamStation provides that data. I am finding it useful in identifying areas of interest with my own central apnea issues.

I would suggest cleaning up the format so more information can show in more detail. Use File, Preferences, Appearances, to uncheck the box that says "Show AHI breakdown Pie Chart", or something like that. It is kind of redundant. Same with the Navigation tool bar on the right. It just takes up space. F10 to toggle it off on a PC. F8 or Shift F8 to toggle it off on a Mac I believe. And if you use the Orange "Write a reply" button at the bottom of the thread you get a full width window to post an image in.

I practice the tongue trick every night when I go to bed. Works perfectly until I go to sleep. My brain doesn't listen to reason when I am sleeping and kind of does its own thing! My wife tried to tell me to suck it up and quit complaining and that a woman could easily learn to keep their mouth closed so a man should too! Well with the help of SleepyHead graphs showing leaks, my complaining about the noise of her mouth leaks, and admitting she was waking up with a sore throat she finally admitted she had a mouth leak problem. The dentist video was the final straw. She uses a TMJ appliance and the video dentist said some things that matched with what her own dentist was saying. After that she become a mouth taping convert...

I have actually found benefit in raising the minimum pressure while leaving the maximum pressure fixed. I only like to raise maximum pressure as a last resort. Raising minimum pressure often eliminates the trigger events which the auto machine needs to be prompted to raise the pressure.

However in this case, with a fixed 14 cm not achieving <5 AHI kind of indicates max pressure will have to be increased at some point. If Flex is being used, I would discontinue that first though.

My current efforts are to get away from using a chinstrap. I dislike it, and I suspect I would equally dislike a cervical collar. I managed to locate a source of the 3M Micropore 2" wide tape locally for a good price of $2.67 for a 10 yard roll. Plan to try that next to see if lets me get away without needing a chin strap. Of all the CPAP tricks I find mouth taping to be the least objectionable. It is much more comfortable than using a full face mask for me. The risk of vomiting with mouth tape seems much lower than filling a full face mask with vomit in my opinion.

I tried 1 1/2" plain masking tape last night as a test thinking it might stick better. I found it did not for me. The glue on the tape seems to soften with moisture and it lost the grip on my face. I wish I could find the Nexcare Gentle Paper tape in a wider size, but for now it seems to work the best of what I have tried. Have never tried the blue making tape, and perhaps it has better glue. I have never like the green painters masking tape, even for painting. It never seems to have enough stick to stay on.

I tried 1 1/2" plain masking tape last night as a test thinking it might stick better. I found it did not. The glue on the tape seems to soften with moisture and it lost the grip on my face. I wish I could find the Nexcare Gentle Paper tape in a wider size, but for now it seems to work the best of what I have tried.

I use a heated hose which has wire in it and is relatively heavy. I started out by leaving it off to the side of the bed where the machine was, but found that it was constantly falling down and the weight of it was pulling on my mask and making it leak. Now what I do is loop it through the headboard so it is supported, and then route it down the center of the bed. I keep it under the covers in a big U shaped loop, so it goes down to about the tummy area and then back up to my mask. I mainly side sleep and when I face the center of the bed, I just leave it there in a big loop under the covers and supported by the bed. When I roll over to face the outside of the bed and the machine I let it cross my body in the tummy area and then route it up my other side still under the covers and supported by the bed. With a headboard that does not allow the looping of the hose, the alternative is to run it between the pillow and headboard and then bring it down the middle of the bed.

There are some masks like the DreamWear system that route the hose up over your head. I have not used one of those types. However, I wonder what they do with all that hose. I find that was my main problem, too much hose, and finding a place for it that was supported and not pulling on my mask.

Hope that helps some,

Your next best step may now be to download SleepyHead and view what you machine is doing during the night. The machine can provide you with some summary numbers, but to see the real detail you need to use SleepyHead. It is free software and runs on a PC or Mac, and needs a SD card reader to get the data off the SD card in the machine. If you don't have a SD card reader, you can get small portable ones that plug into your USB port for as little as $5 at places like Walmart. If you are interested here are some links:

SleepyHead Download

SleepyHead Basic Manual

The value in looking at your data is that you can see when you are having apnea events and at what pressure. If for example you see that your machine is running about 10 cm over the night, then you know you will have room to move up your minimum pressure and ramp start pressure a little higher still. I started with my ramp start pressure as low as 5 cm and that was not comfortable. Over time I have increased that based on comfort in going to sleep and now have it set at 9 cm.

I think one thing to consider is that the apnea treatment industry is not very old. It only goes back to the early 1980's and it was pretty crude back then. The discovery and use of insulin for diabetes in comparison started 60 years earlier. My observation is that the industry is in a state of major change. The method and who does treatment varies widely from country to country and region to region. Some treat it as a very serious disease, and others that it is an elective treatment.

In the US under the government and private insurance thumbs, it seems to be very prescriptive. The expectation is that you will do an in lab sleep study, if positive then an in lab titration test, a trial CPAP (not APAP), if that fails then an APAP, and If that fails a BiPAP, and if that fails than perhaps an ASV. In Canada we seem to be all over the map. Some provinces cover the cost. Some do not. Some will allow prescription from a home study test, and some will not.

And, then there is the industry politics and financial realities. In the province I am in, the cost of a CPAP is not covered by government health care, only private insurance. The government however has allowed in the home study sleep clinics without any requirement to have a doctor on staff as long as they consult one to read the test results. He(she) does not even write the final prescription. That is left to the GP that ordered the test. I doubt my GP really even knows what a CPAP looks like. These clinics cover their costs by charging exhorbitant prices ($2400) for equipment available on line for $850. This has the "old boy" in lab sleep clinic people who have invested in facilities to do the in lab and titration tests all upset. They have now lobbied the government to upgrade the standards to force these upstarts to have a doctor actually on staff, although it does appear to only be somewhere. They have also forced higher education standards for the technicians administering the testing, and dispensing the machines. Here is a link to the news story on it. The regulations are still not going to be in force for another couple of years or so.

The other problem in the industry, and that may be more widespread across countries is that the profit seems to be wrapped in the sale of a machine and frequent supplies at exorbitant mark up prices. The on line stores are cutting into their game. But, the issue is that they ideally want to test you, get a diagnosis and prescription for a machine, sell you and expensive machine, and then hope you never come back for help or have any questions.

My thinking is that the on line stores are here to stay, and the at home sleep study is going to become the first line of diagnosis, followed by an immediate trial of an APAP, not a CPAP. In the future this is going to drive down the cost of equipment sold by clinics and they are going to have to become more responsive to their patient needs. For example train them to monitor their results adjust their own machines, rather than keep repeating titration tests, and adjusting machines for patients.

Bottom line? One needs to look after their own interests. The better you understand how the industry works, and understand the basics of treating the condition, the better you can look after yourself. Just my thoughts...