Sierra

It is interesting that you should post about the link of hearing loss to CPAP use. We just got back from a hot south vacation where we had the AC running all the time. At home our bedroom is very quiet, but at the resort the AC was quite noisy in comparison. But, the interesting part was that when I woke up in the night, and was trying to get back to sleep, I noticed that as I was breathing the AC noise would stop and start. And, it was not the AC stopping and starting, it was my hearing cutting in and out. So, after that experience I have no trouble believing that CPAP treatment could affect hearing at least temporarily. I have noticed for some time now that about an hour after I get up, I get kind of a dizzy feeling. I think it must have something to do with a pressure equalization issue in my ears. The temporary hearing loss may be another symptom of the same issue. I don't really have a solution, other than it may have something to do with nasal congestion and sinus issues. It may be worthwhile seeing a ear, nose, and throat specialist to see if there is a treatment. Your other issue seems to be swallowing air. The common solutions are using EPR or Flex, and if possible getting pressure lower. But, it appears you have already tried the lower pressure.

Another update on my testing of Auto vs Fixed CPAP pressure effectiveness. I have kind of gone through three phases with this testing:

Standard Auto Mode - This is the setup where most machines are put in for patient use. A common starting point is 5 cm to 20 cm. Then if one is fortunate to have an attentive sleep technician, this range gets a further refinement based on data collected over the first month or so. Since my trial machine was not compatible with SleepyHead, I don't have a record of the first two weeks, but I recall I started out something like that. Fairly quickly I reduced that range based on what I was seeing in SleepyHead to the 10 cm to 15 cm range. The outcome of this phase was getting AHI fairly reliably under 5.

Limited Auto Mode - My next strategy was to try and optimize the set pressures by narrowing that range more and more. I also, with thanks to a post by sleeptech at this forum switched to a EPR on ramp only. Using EPR on ramp only resulted in a reduction in pressure, and that was further improved by narrowing the range of pressures allowed. The outcome of this phase was getting AHI down to the 3 range.

Fixed Pressure CPAP Mode - My third and latest strategy has been to try the fixed pressure mode. I was getting suspicious that even with a narrow pressure range, the machine was running pressure up too high and was increasing the frequency of central apnea and hypopnea events. My thoughts were to keep reducing this fixed pressure setting until obstructive events started to increase. Unfortunately I have not been very disciplined about leaving the pressure at one setting long enough to collect sufficient data. But, that said a pressure of about 12 cm gave me an AHI of 2.3 over 15 days. And now at my latest longer term trial at 11 cm for 19 days I have an average AHI of just under 2. For many with basic apnea that probably does not sound that great, but for me where most of my apnea is central, that is pretty good.

What is my conclusion in all of this? Well, first off, one person does not make a study. My AHI at diagnosis was about 34, and there was very little central apnea identified. However, with PAP treatment, central apnea increased, and really has not decreased after the 6-8 weeks that some studies have shown. It stayed high with my apnea remaining mixed, with the highest portion being central. So these results may only apply to someone in a similar situation, or where there is at least some central apnea in the picture. But, for me, it appears a fixed pressure CPAP mode has been much more effective than a wide open auto mode, and better even that a limited pressure auto mode.

Could someone get to this point by starting with a fixed pressure CPAP machine instead of an Auto CPAP? Yes, possibly, BUT, I think it would be very difficult unless the machine stores detailed data on a SD card that can be read by SleepyHead. One would have to try one pressure for at least a week if not 2-3 weeks, and then try another pressure. It would take a long time, but I suspect it can be done. The Auto machine allows you to identify the range of possible effective pressures very quickly, which in turn makes the testing for ideal single pressures quicker. And it is kind of a moot point anyway as the last time I checked the cost of the ResMed Autoset is only about $80 more than the ResMed Elite fixed pressure machine (which has data capability). To me it makes much more sense to start out with the Auto machine, and then switch to fixed CPAP mode later if that works better.

Hope that helps those who are dealing with this issue. The biggest benefit in all of this for me is that I find my sleep more comfortable now with a fixed pressure. A fixed pressure of 11 cm is certainly more tolerable than an auto mode which was running pressures up to 15 cm, while potentially causing more apneas than it was avoiding. Here is my sleep report from last night which is better than average for me, but somewhat typical. And I will also attach the Statistics page which kind of details my journey through these three phases identified above. To date I have now tried 30 different setups!

Mike, in comparison to the example I posted your machine is well set up. You, or whoever has set it up have done a good job of taking control away from the DreamStation. That is why your pressure response is so flat. The minimum pressure has been raised thus taking control away from the machine. You could go one step further and simply set the machine into fixed pressure CPAP mode and set it at about 9.5 to 10 cm. That is where I am currently at. I have ran auto pressure with it running up as high as 15 cm, but I am now getting better results with a fixed pressure of 11 cm.

The example I posted was picked because that machine was set up with a low minimum thus giving control to the machine. That is why you can see the hunt and peck classic pattern of the DreamStation. That machine is poorly set up, and is essentially in the default setup mode that unfortunately many sleep clinics put it in. My suggestion to improve that setup would be to increase the minimum pressure to 9 cm and reduce the max to 10 cm, or just set the machine to fixed CPAP mode at about 9.5 to 10 cm. Ramp start could be about 7 cm.

With your mask noise on the ResMed AirFit P10 the problem may be a combination of items. When you first go to bed it is normal to breathe more air in and out until you relax. And in addition with a new user of a CPAP one tends to be anxious and breathe even more. This can be aggravated by a start pressure that is too low, so you feel like you have to breathe more heavily. The higher flow rate increases velocity of the air, and makes some noise. If the mask insert is too small that velocity increases even more. So to avoid it, make sure your start pressure is not too low. I would suggest not less than 7 cm ideally, and I actually use 8.4 cm in my machine. I also use the large insert size, even though the medium seals better. Here is an example from SleepyHead of what air flow looks like in SleepyHead when I was going to sleep after getting up in the night, going downstairs, and then back to bed. I probably was a bit out of breath. You can see that the flow volume (Minute Ventilation) started out at 30 and dropped to about 8 after I relaxed and got my breath. When breathing heavy like this I do hear some noise, but I find it goes to nothing after I stop breathing hard.

Mike here is an example in SleepyHead of how the DreamStation behaves, and what I mean by a more bumpy ride.

Notice how the pressure goes through very large swings both up and down. And on top of that you can see the spikes in pressure which happen periodically. That is the machine doing the hunt and peck method to see if the pressure should be changed. In comparison the ResMed gives a much smoother ride. But, if one does not notice it, then both machines can do the job.

The ResMed AirSense 10 has both a standard and a soft response. So, you can dampen out the response even more if you want to. I have never tried the Soft response setting, so don't know what it really does from experience. I see it there as an option though. The For Her mode is slightly different than the response setting. It gives a quicker early response to hypopnea, and holds the increase longer. It will not go above 12 cm in response to obstructive apneas, so that setting will work for some, but not others that need higher pressure. I was not aware of the For Her differences when I bought my AirSense 10 machine, or I would have bought one. I thought it was just an appearance difference.

Flex on the DreamStation is a bit different than the ResMed EPR. The EPR gives a full 1, 2, or 3 cm reduction in exhale pressure. The Flex technique although it uses the 1, 2, 3 number system, does not really reduce pressure by those increments. It just changes the shape of the pressure switch from inhale to exhale. And, to my knowledge DreamStation does not have the option to use Flex during the Ramp only. It is either on or off the whole time the machine is running. Here is a link that explains how different manufacturers do the expiratory relief.

Comparing Expiratory Relief in Different Machines

You may also want to check with your insurance company directly for any other options. My son had employer Sun Life insurnce, and he worked out a deal with them to buy both a home machine and a travel machine, on line for a total cost of about $2000. The insurance company went for that as it saved them about $500. Not totally sure of the value of a travel machine, but in case you are interested it may be an option.

As for the two choices of machines, they do basically the same thing, and both are supported by SleepyHead. If you are going to try them both, I would suggest downloading SleepyHead so you can see how each machine operates for you personally. They do behave a little differently. You can also access this basic SleepyHead manual for some help using it. You do need a SD card reader and a PC of Mac computer for it though.

The Dreamstation uses what has been called a hunt and peck method of controlling pressure. It bumps pressure up every 10 minutes or so to see if breathing is improved. If it is not, then it ramps back down again. It results in a more "bumpy" pressure ride during the night. The ResMed tends to respond faster, and then maintain the pressure longer, giving a smoother pressure ride. But, if you use SleepyHead during your trial, you will see that. SleepyHead will allow you to use multiple machines in your same setup.

My preference in the two machines is the ResMed AirSense 10 AutoSet For Her. The For Her version gives you a choice of another algorithm which you can use at your option. It also offers the standard one with a mode change. The price on both machines are the same.

Other than the smoother pressure ride, the nice feature with the ResMed is that it lets you use EPR (expiratory pressure relief) during the ramp only. That is better than having it on full time or off full time in my opinion. It also offers an Auto Ramp feature that I find very comfortable. Instead of ramping up pressure, it holds the pressure at your selected level until you go to sleep. So you get the comfort of EPR and a fixed pressure while you are awake, and then it switches over to more effective treatment pressure with no EPR, when you fall asleep. The only bit of an issue is that some sleep clinics can't be bothered to set the machine up properly to use these more advanced features. It can be easily done yourself though. Here is a link to a Technical Manual which describes how the machine works and what the options are.

Here is an example of how the ResMed machine operates when set up with the AutoRamp and EPR at 3 on Ramp Only. You can see the pressure cycling (Mask Pressure) during the going to sleep mode, and then stop cycling when you fall asleep. You can also see how the pressure self adjusts during the night to events.

If the machine is getting you down to 1-2 it is highly unlikely you have any significant central apnea issues. Getting the right mask is often the most difficult part. I started with the P10, and then tried the Mirage Quattro, and F20 full face masks to solve the mouth open air loss. I couldn't get them to seal and rejected both. I then tried a mirage nasal mask and did,'nt like it either. Next I tried the F&P Brevida. It was OK but seemed to irritate my nose more than the P10. So now I am back to the P10, and use a Breathewear Halo chin strap, and also tape my mouth (horizontal). I find the P10 very quiet. I believe it is rated at 21 dB, while the Swift is 24. You may be using an insert that is too small. If you buy a new one they are usually sold as a fit pack, which means you get three sizes of inserts. I believe it makes the most sense to use the largest one that will still seal.

On machines I would recommend the Australian ResMed AirSense 10 AutoSet For Her. The For Her model offers an extra algorithm and is the same price. My second choice would be the US Dreamstation. Both are compatable with Sleepyhead.

An AHI OF 0 TO 5 is considered to be normal. 5 to 15 is mild apnea, 15 to 30 is moderate, and more than 30 is severe apnea. Yes a PAP machine is your best choice. I would try to get an automatic model, or APAP. IF you are paying for it yourself you probably can get on at a lower price on line, compared to buying it from a sleep clinic.

If you download SleepyHead to view your data, I believe it has some setup options where you can select when it switches over to a new night.

See the posts started by SirRobin. He is from BC and I have given him the basics on how to set up a machine. You also may want to consider the For Her version of the AutoSet. It does all the same things as the standard machine, costs the same, but has the extra optional For Her algorithm. It may or may not work for you, but is easily switched to the standard algorithm.