Sierra

It is surprising that it pushed pressure up so far and so quickly. You are getting some flow limitation indications on that graph, and the snore chart is not visible. Both can drive pressure up even in the absence of flagged OA and hypopnea events.

Another option would be to set a maximum pressure of say 7.6 cm to keep the pressure from going too high.

One other thought. I believe the S8 series machines have Expiratory Pressure Relief, or EPR. It seems to me that you could set the S8 to a set pressure of 20, and an EPR of 3 to get essentially the same thing as a 20/17 setting on a BiLevel machine. Or is your doctor anticipating that you are going to need more than 20/17 for pressure?

I have no personal experience with the BiLevel machines, but I have looked at them as a possible solution to my higher than average central apnea frequency. The one I would pick is the AirCurve 10 VAuto. It is capable of being set to the Auto mode, S mode, and CPAP mode. See the link below for a feature comparison of the models, near the bottom of the link. I also think this may be the most reasonably priced model depending on where you shop. What country are you in? The only value in shopping for a S9 model would be a possible lower price. The AirCurve 10 models are the newest and it would seem if you are getting a new machine you may as well get the latest model with the latest features.

ResMed AirCurve 10 VAuto

Those first CA events in this series look to me like you were breathing normally and then just stopped. Not sure of the potential cause of those if you were sleeping. The last one looks more typical where the breathing flow is normal and then slowly tapers off to none, and then the apnea. That can be caused by an upset in the CO2 and O2 levels that your body does not adapt to quickly enough. Kind of like a cruise control that does not act fast enough and then over reacts.

You do not have to get less air when you use the Auto Ramp and set the EPR to Ramp Only. The trick is to set the Ramp Start pressure to the same as your minimum pressure - say 6 cm. You will get the full 6 cm and it will only cut back on exhale. Then when you go to sleep the EPR function will stop and both inhale and exhale will go to 6 cm.

But I think the main thing for now is to stop the EPR when you are sleeping and get the minimum to 6 cm or 7 cm at most.

It looks to me like those CA events are occurring only when IPAP pressure is above 8 cm. Turning EPR off and setting your minimum pressure at 6 cm may avoid them.

Those CA events do not look like the ones I see when I am sleeping. Any idea if you were sleeping at the time they were happening?

A format suggestion. You seem to have the CA events flagging turned off. If you turn it on, then you should be able to see when the CA events are occurring and at what pressure. If you can post the same reports again but with the CA flagging turned on it would be helpful.

My initial thoughts are that the EPR may not be doing you any favors. I think I would turn it off, and set the minimum pressure at 6 cm. That should give you enough air to feel reasonably comfortable, and possibly avoid some of the CA events. It is possible that the pressure will just stay at 6 cm and not go up any significant amount during the night. It seems you do not need much pressure to address the obstructive events.

If that works then you may want to turn the EPR back on again but set it for Ramp Only, and then set the Auto Ramp start pressure at 6 cm as well. This will give you the EPR to improve comfort during the ramp hold period, and then shut it off when you go to sleep.

Another thing you may want to do is zoom in on a period of time when you are having a lot of central events. You can do this by repeatedly left clicking in that area. Using the up down and sideways arrows can fine tune the location and zoom level. This will allow you to see what the central apneas look like in the flow rate graph. Posting one of those would be helpful too.

Are you able to post a SleepyHead chart for a couple of the nights? A good one and a bad one?

With a PC all you have to do is press F12 with the window maximized. A screenshot will be saved under Documents/SleepyHeadData/Screenshots. With Windows Explorer just drag the saved files to the body of a message you are composing. They will upload and be displayed as a thumbnail which can be expanded for viewing. The daily report has a lot of data on it that is very helpful in determining what is going on.

This question has been subject to a lot of debate as APAP machines have become less expensive and the trend has gone away from using overnight in lab titration studies to determine what pressure to set a fixed CPAP at. In any case here are my thoughts based on 6 months experience using an Auto CPAP (ResMed AirSense 10 AutoSet). In the beginning I would have answered this question without hesitation and said that an Auto CPAP is the obvious choice. But, my experience has led me to a slightly different conclusion now.

Auto CPAP or APAP: With the cost of an in lab titration test going up and the cost of an APAP going down they have certainly become more popular. The more common method of prescribing them now is to do an at home sleep test (like I had) and then prescribe an APAP as a trial. Follow up is done to see what adjustments are needed to the pressure settings, and then that is about it. The machine is left to kind of self adapt to the user needs. Sounds good, but does it give the best results?

Fixed CPAP: To be properly set up they require an in lab titration test where different pressures are tried for about an hour at each pressure during the night to see what works best. Based on the test a fixed pressure CPAP is prescribed and the patient left to use it. If it works that is it, until treatment becomes ineffective and then they are most likely required to come back for another expensive titration test to see if adjustments are required. Not surprising that insurance companies are liking this route less and less and pushing for the use of an Auto CPAP.

My conclusions based on going the Auto CPAP route have evolved over the last 6 months, and my current thinking is that there are really two answers to this basic question.

1. The Auto CPAP route certainly makes a lot more sense to minimize the cost and time to get a patient into treatment and maintain it over the longer term. If one uses software such as SleepyHead you have the ability to see how well the machine is performing and whether adjustments are needed. Some will choose to do those adjustments themselves, while others will make requests of their provider to do the adjusting. Either way, the outcome is pretty good. However, what is debatable is whether or not the effectiveness of the treatment is the better than a fixed pressure CPAP.

2. My conclusion is that while the APAP machine is the right choice, at least for some, there can be an improvement in treatment effectiveness by going to a fixed pressure instead of a variable pressure, once you know what pressure you need. Fortunately most APAP machines have that feature built in and it is a simple configuration set up change to make the machine work as a fixed pressure CPAP. And with SleepyHead you can come up with a pretty accurate estimate of needed pressure without undergoing an in lab titration test. You can get the information from the APAP machine data.

Why do I think that? Well it may be slightly premature, but I am 12 days into a fixed pressure mode trial and am actually seeing improved AHI results compared to running it with variable pressure controlled by the machine. My AHI has improved to an average over this period of 2.4 compared to a long term average with the machine on Auto of 3.2. Not a huge difference, but an improvement. I notice no difference in comfort, and if anything have fewer major leak episodes.

While it may seem regressive to set a fancy auto machine into manual mode, it may actually improve the results you get. I think the reason for getting better results is quite simple. Pressure is increased as soon as the ramp (if used) ends. This eliminates the need for apnea events to trigger an auto increase in pressure. Yes, you do have a few apnea events which may have been prevented if the machine was allowed to go higher than the fixed setting, but taken together more are avoided by the early ramp up of pressure.

So, I throw that out there to share what I have learned and for comments. As always one person does not make a study, but it seems to be working for me.

I have tried 5 different masks so far, and I am back to the first mask I tried which is the same AirFit P10 you are using.

Tried a Mirage Quattro full face, and it was a disaster. I couldn't make it stop leaking. It blew air in my eyes and made rude noises. I never got to the point where I could wear it a full night.

I tried a ResMed AirFit F20 full face and it was better, and I managed to wear it a total of about 5 full nights. However it still leaked some, and when I got it to the point where leaks were reasonable it started to make a blister on the bridge of my nose. Gave up on it. I never tried the cloth mask liner trick, and that may have helped.

Also tried the ResMed Mirage FX Nasal mask that my wife uses. It was more comfortable than the two full face masks, but not nearly as comfortable as the nasal pillow, and had all the disadvantages of not covering the mouth.

Tried a F&P Brevida nasal pillow based on some rave reviews of it. It was pretty good and has a much better headgear with a sensible adjustment system compared to the P10. However, it seems to stick out more than the P10 and seemed easier to dislodge when changing positions at night. I had the fit pack and tried both the large and small. But, it in particular irritated the part of my nose between the two nares. I pawned that one off on my wife and she finds it much better than the Mirage FX. The small size restricted flow on exhale, but the large size works for her.

That brings me back to the P10 which I am using again after the mask merry-go-round. I had trouble keeping it on all night, and was opening my mouth letting air out and causing a major leak. I now use a Breathewear Halo chin strap and it sure keeps the mask on all night. It did not totally solve the mouth opening problem, so I reluctantly tried the tape on the mouth trick with 1" medical paper tape. I have now gotten very used to it, and have many night with essentially zero leakage. It is quite the Jerry rigged setup but it works for me.

As for the nose irritation I tried the medium and large insert sizes. The medium sealed better but seemed to go too far into my nose and irritated the skin quite a lot. The large is now working best for me. As for the nose irritation mine seems to be mainly on the exterior edge of the nares. In the morning after taking my mask off and showering I put some OTC 1% hydrocortisone cream on my nose. I found after doing that for a week or two the skin toughened up and I no longer need the cream.

Hope that helps some,

I believe in the US the standard treatment is to start with a CPAP or APAP, and if that fails then try the BiPAP, and if that fails, then the ASV. There are some medical limitations on who can use an ASV as well.