Sierra

I answered most of this a bit further back in the thread. Here is a copy.

A setting of 10 is moderate. The machine is capable of going from 4 cm to 20 cm. I am now using a pressure of 11 cm. If you are going to run the machine in the For Her Auto Mode, and your recommended fixed pressure is 10 cm, I would set the minimum pressure to 8 cm, and the maximum to 11 cm as a starting point. Then after some experience with that setting and using SleepyHead to monitor the results, you can either refine those pressures, or go to a fixed pressure based on actual experience with the machine. Here is a cut and paste copy of what I gave another user of the ResMed for initial setup for comfort.

• Ramp Time: Auto (This will hold the machine at the start pressure until you go to sleep)
• Start Pressure: 7 cm or more (I would not set it at less than 7 cm unless your minimum pressure has to be less than 7 cm. You can't set Start Pressure higher than your minimum pressure. I adjust this pressure even higher to give me a feeling that there is no mask on my face at all. This pressure should be high enough that breathing is very free and easy)
• EPR: On
• EPR Type: Ramp Only (The purpose of Ramp Only is to give more comfort while going to sleep and a more effective therapy pressure after you go to sleep)
• EPR Level: 3
• Climate Control: Auto (providing you have the heated hose)
• Tube Temperature: 27 C

A little further down on the setup menu under Options you will find this item:

• Essentials: Plus (Setting it to Plus will give you more options on your User Menu, and a more detailed Sleep Report.)

If the issue of apnea events right as you go to sleep is not solved by this, there are other options. But I would start with this.

Here is a link to a video on how to set the AirSense 10. I would also download SleepyHead so you can monitor the results you are getting from day 1. The settings may have to be adjusted a little based on your actual experience with the machine. Another poster put some examples of SleepyHead reports a little further back in this thread.

You for sure want to get a hard copy or pdf copy of your sleep report. You will want it for future reference as to where you started this CPAP journey, and if you ever want to buy even a mask, you need it in the US.

Yes, this is probably quite easy to fix if you are prepared to go into the Clinical Menu and change some Comfort settings. This assumes there is nothing physically wrong with the mask and the tubing such as being kinked or plugged. That is highly unlikely. You should also make sure you don't have the mask adjusted too tight so those nose cone things are not crushed.

Here is a video on how to get into the Clinical Menu.

Once there here is how I would change your Comfort settings to reduce the breathing effort. Scroll down to them and set them as follow. This should be in order of how they appear on the menu.

• Ramp Time: Auto
• Start Pressure: 6 cm
• EPR: On
• EPR Type: Ramp Only
• EPR Level: 3

While you are there, it would be helpful to also scroll down to near the bottom to Options and set one more parameter there. It will allow you a bit more control from the User Menu, and give you a better Sleep Report

• Essentials: Plus

That should improve the breathing effort while going to sleep.

When you post a screenshot from SleepyHead, it really helps to optimize the layout of the Daily Detail screen first. On a PC, F10 will get rid of that redundant tool bar on the right side. If you go to File, Preferences, Appearance, you can uncheck the box that says Show Event Breakdown Pie Chart. It is kind of redundant too and covers up more important data. In your case it will be important to show the Snore graph. You can click on the title and drag it up the screen. Leave the Events Flag pinned to the top as it should be by default.

To make the screenshot just press F12 on a PC. A message will pop up showing where the screenshot file is saved. Go there with Windows Explorer and left click on the file, and drag it into the body of a message here. Start a new message with the Write a Reply button so you get the full width to display.

EDIT: I forgot one format issue. Click on the triangle beside the date to hide the full month calendar. It also takes up space that hides more important info.

Zack, just to confirm, I take it your settings are as follows? This site can mess up the format sometimes and make it hard to read.

• Mode: S
• IPAP: 25
• EPAP: 17
• Easy-breathe: on
• Ti max 3.5s
• Ti min .3s
• Rise time: min
• Trigger: med
• Cycle: med
• Mask: nasal
• Ramp time: 20min
• Start EPAP 8.0
• Humidity level: 5
• Tube: slimline
• Leak alert: off
• Smart start: off

First off, if you do not have the link, here is one to the technical manual that explains more about what these settings are about.

AirCurve Technical Manual

From the description of your concerns, it seems the machine is working well for you, except for the snoring when on your back. The problem could be the IPAP or EPAP pressure settings are too low. Your IPAP is already at the maximum of 25 cm, so about your only choice would be to increase the EPAP pressure up from 17 about 1 cm at a time to see if that helps. One issue with increasing EPAP is that it will reduce the differential between EPAP and IPAP, which in turn reduces the breathing assistance effect of the machine. There could be consequences to that. So, you would only want to make a small change and try it for a while to see if there is anything negative happening.

The S mode that your machine is in, is quite complicated, and it looks like it has been highly customized to your needs. The S mode also includes a back breathing rate of 10 bpm. You could switch to CPAP mode but then the maximum pressure is limited to 20 cm, which probably is not going to work well at all. You could also switch to the VAuto mode and let the machine adjust the pressure. That could work from a pressure point of view, but you would lose the Easy Breath and Backup Rate feature. There must be a reason why the machine was put in the S mode to give you those features. Switching to VAuto would not be at all advisable without consulting your sleep specialist for advice.

The other option at this point, short of going back to your sleep specialist is to download SleepyHead which is a free software to view your detailed machine data on the SD card. You need a PC or Mac, and a SD card reader. There should be substantial data on the card that will show where you are now, and how it has changed over time. It would also show exactly when you are snoring, and how it has changed over time. Here is a link to a basic manual on how to use the software. If you could post a screen shot of your daily report here, it would be very helpful in understanding in more detail what the issues are. It would also document whether or not you are making any improvement by increasing EPAP.

However, when looking at where you are, unless it is not possible to do, I would consult your sleep specialist for advice even before increasing EPAP.

Hope that helps some,

I think the purpose of that Inspector General report was to focus on the less durable, more consumable components needed for CPAP. That SleepApnea.org link did include the Medicare replacement recommendations for the machine and humidifier. A quote:

• Heated Humidifier - E0562 - 5 Years
• CPAP Machine - E0601 - 5 Years

Those intervals seem reasonable to me. On other equipment, I'm quite sure I could make my AirFit P10 last a year, but I am getting a bit fed up with it. It is probably due for a cushion replacement, so it is either that, or a complete new mask. I placed the order today for a new Swift FX. I hope it works. It seems to get good recommendations from this cpapreviews.org site. The author of the blog claims to be a cpap user, and has used both the P10 and the Swift FX. I hope he is right that it is a good mask. I recall another contributor here, SnuzyQ, had good things to say about it too. This will make #6 that I have tried!

I have been into this CPAP thing for over 9 months now, and my wife is around 4 years. She is on her third mask in 4 years. While I have tried 5 different masks, I am back to my original AirFit F10 nasal pillow mask. I am starting to think I need to at least replace the nasal pillow cushion part, but I really don't think there is anything wrong with what I have. I have never been happy with the headgear of this mask, and actually have modified it by cutting the straps and sewing them up to make a tigher fit. So, what I really may do is replace the whole mask with the very similar older design, Swift FX, to get a more adjustable and durable headgear part. Our insurance does not cover CPAP at all, so we pay 100%, and can replace any time we want to pay!

It motivated me to do some research on what is recommended for replacement frequency. Of course there is no shortage of recommendations from self interested parties such as manufacturers and suppliers. And they are very conservative as one might expect. I found one somewhat independent source, SleepApnea.org, which simply presented the US Medicare maximum allowed replacement frequency. It seems very very generous! Then I found a US Department of Health and Human Services, Inspector General, report which reviewed the US Medicare, and state Medicaid recommendations for replacement frequency. In short they found the frequency was far to frequent and all over the map when you look at the state Medicaid allowances. This table from the report kind of summarizes their findings.

Wow! Some states allow heated hose replacement twice a month, masks and humidifier chambers once a month, and cushions twice a month! Seems incredible. My wife is using her original heated hose and humidifier chamber which are 4 years old. The lowest state allowance seems much more reasonable to me. And some of these components have a 1-2 year warranty. The Inspector General issued a report which has much more detail, and recommended a significant reduction in the allowance. It was rejected. To be fair, these frequencies are maximum, and the clinics are expected to only replace as necessary. More money in their pocket though, if they replace often when not limited by Medicaid or Medicare.

So, if you were controlling the purse strings how often would you pay for replacement of the typical components?

It is good to hear that more humidity helped with the headaches. I use a ResMed AutoSet machine and have never used the DreamStation. With my ResMed set to Auto humidity with a heated hose, and the temperature set to 27 C, it pretty much uses the whole reservoir of water with an 8 hour sleep. That would make me suspicious that the DreamStation auto function may not be working properly in your machine. Water consumption stays pretty much the same from summer to winter, and also when traveling. My only concern is that it may run totally dry some night...

Which specific model of the AirCurve machines do you have? What are your pressures set at? Is your AirCurve working well for you otherwise? It could be set to fixed pressure CPAP mode. Or it could be setup much like the AirSense 10 Auto mode too. If you are only having the issue on exhale, it would suggest the EPAP pressure may be too low, or the pressure support too high.

Be careful what you ask for!

Physiological consequences of CPAP therapy withdrawal in patients with obstructive sleep apnoea

"In conclusion, the findings from the CPAP withdrawal RCTs have provided robust evidence for increased sympathetic activity in OSA associated with a considerable blood pressure increase, relevant cerebral hypoxia, and disturbed cardiac repolarisation. Furthermore, the blood pressure lowering effect of CPAP was further proven. Additionally, the findings of these trials have challenged previous hypotheses on the role of intermittent hypoxia in oxidative stress and vascular inflammation, and have suggested a so far unconfirmed mechanism of hypoxic preconditioning in OSA."

My layman translation: CPAP works, has benefits, and those benefits are reversed when you discontinue use.

As an Australian, you might find this article interesting. If nothing else it may be a sure fire way to treat insomnia, as it is 64 pages long. It is about the history of ResMed, and Colin Sullivan who I believe are credited with inventing CPAP therapy. The journey started not that long ago in 1981 with the use of a vacuum cleaner motor and fan to supply pressure for OSA treatment. What is surprising about it is that much of the effort was not in the technical development of the product, but in getting acceptance that OSA was a legitimate problem and could be treated. They also spent a lot of time in court fighting over patents. I believe if I recall correctly that Respironics (now owned by Phillips and use the DreamStation brand name) actually beat them to the market, and at one point they were very close to merging.

Perhaps their biggest issue was in convincing medical professionals of the time that CPAP worked and OSA was worth treating. I think you are basically questioning the same thing. I would be easy to say it is a big conspiracy as the demand for the product was created by the inventor of the product. It started our as the solution in search of a problem.

Origins of ResMed

You bring up the dental appliance solution. The basic issue with it is cost. If done right, it is not inexpensive. My preliminary research on it in Canada put it in the range of $3000-4000. Kind of high compared to a CPAP system at about $850. I think where a dental appliance solution comes into its own is when low pressure causes excessive central apnea. It should provide a unique way of correcting lower levels of OSA without increasing CSA -- because it uses no pressure.

First off, I am not a medical professional, just a CPAP user that takes some interest in the technology of the machines. My observation is that the apnea treatment field is in transition. The old traditional approach was to do an in lab overnight PSG. If it was positive for apnea, then the next step is an overnight titration step in the lab to determine the fixed pressure for a CPAP. You are sent away next with a trial machine set up to that pressure, and after a week or a month then you bring them the results for any tweaks required to the pressure. Now with the auto CPAP or APAP so common and inexpensive, I would say most clinics would simply set up the machine with a wide range after the positive test and jump to the at home trial stage. And the even more later development is the use of the ResMed and Phillips at home sleep study equipment. Labs here in Canada that use the at home approach, would have gone from your first positive test of moderate apnea to the at home trial of an automatic machine.

This process gets complicated a bit by the various jurisdictions, the US Medicaid system, and insurance companies. They can force a stepped approach; Sleep Study in Lab - Titration Test in Lab - Fixed CPAP - At home trial - If that fails, then APAP, at home trial, ..... If you have insurance and are essentially paying a substantial amount it makes sense to me to cut to the chase for economics and expediency. The condition however is that is in the absence of complicating factors such as heart and lung disease or other issues. The basic no complications process leaves out the in lab tests and titration and just jumps straight to an APAP.

If you want to go that route and you can see a GP soon, perhaps just ask the GP what he/she needs to write a prescription. If the system is the same as Canada, the GP can request a copy of the report from the sleep specialist and use that to write a prescription for a machine. I believe the same as in Canada courts have determined that medical records belong to the patient and the medical profession has no right to withhold them from you.

As for a machine the suggested ResMed AirSense 10 AutoSet is a good one, probably the best on the market. It comes in a For Her version which is the same price, but includes an extra optional mode that has been optimized for women and potentially can work well with men too that have lower pressure needs (<12 cm). I have the standard AutoSet, but if I was buying again I would buy the For Her version (despite the color and flower pattern!).

Setting the machine up is not that hard, and you can monitor your results as you have already determined with SleepyHead. Assuming you are in the US it pays to shop around for prices on machines. There is a place called SecondwindCPAP that sells both used and new machines at good prices. There may be better places. I am from Canada so have only shopped seriously here.

The final issue to consider is that not everyone adapts well to using a CPAP, and typically the mask is the biggest issue. Here, the sleep study companies offer a free trial of a machine for two weeks. They also put ridiculous prices on their machines (like $2400 for a machine and mask). But, here at least you can do the trial as I did, then return the machine and buy the machine and mask on line for $850 or so. I am assuming if you go down the GP prescription and buy it yourself route, then you have bought in, and can't back out. There are some companies such as CPAP.com that offer return insurance on some things like masks, but I'm not sure about machines.

You may also want to contact your insurance company and make sure they are on side with your course of treatment. Generally the lower the cost to them, the happier they are, but when you deal with bureaucracy you never know!

Hope that helps. If you have any questions, just ask...

Here is a link to an article that discusses how the apnea field has evolved, and the reasons around it.

AutoPAP vs CPAP