Whipper

Hi All. I’m a new member, but not new to CPAP or the forum. I have read many of the threads on your forum as I walked myself through my first year of therapy. I decided to join today because I’ve reached a sticking point in my therapy. I’ll begin with a note on my history. I started CPAP with a Resperonics Dreamstation APAP and nasal cushion last January and found this forum shortly thereafter. Not having any guidance from a sleep physician or much from my DME, the wonderful folks on this forum provided guidance that allowed me to acheivce very good success with my treatment by dialing my machine in. Along the way I found that I needed a tight chinstrap and tape over my mouth to achieve good numbers (and some good sleep) since apparently I am a mouth breather. Last May, I tried a Simplus FFM, but could not get comfortable with it, so I returned to the chinstrap and tape. I had even a little better success with the Dreamstation nasal gel cushion when it came out. I picked up a Dreamstation FFM three nights ago with the hope that I could ditch the chinstrap and tape (I have to wear the strap tightly; it’s hot and I also have some jaw discomfort). Lastly, I often have upper airway nasal congestion and, I guess as a result, frequent high Flow Limitations as recorded by the Dreamstation.

Here are the basic average results over the last year after dialing in:
1. Pressure Range 8-12, 239 days, AHI .75, RDI 1.70, FL .46
2. Pressure Range 8.5-11, 21 days, AHI .75, RDI 1.73, FL .56
3. Fixed Pressure at 8.5, 47 days, AHI .55, RDI 2.06, FL 1.05

My best sleep subjectively has been with the 8.5 fixed pressure. My hope with the FFM was to be more comfortable (no hot tight chinstrap, tape) and, perhaps to reduce the flow limitations somewhat (the DME respiratory therapist said that I should achieve that as a result as well). The therapist also recommended a small frame (I always wore a medium before). I didn’t know that she also gave me a small cushion as well until after the first night (it has an S on the one side where the frame plugs in).

The first two nights were spent tweaking the mask adjustments. I had only fair results. I ditched the small frame for a medium after the first night. The mask is very comfortable with the medium frame but, perhaps, the small cushion is too small even though it “feels” OK.

Last night had three main sessions and I have posted them below. I was cautioned by the DME rep not to tighten the straps on the FFM too tight; to wear it rather loosely. The Resperonics FFM manual says this as well. So, I began with a comfortable, but loose fit. The first session was a disaster as far as numbers go (7.76 AHI, 8.62 RDI, .86 FL) and I only slept a little over 2 hours. After a brief second attempt in which I could not go back to sleep, I put my nasal gel pillow, chinstrap and tape back on and slept for 4 more hours comfortably. Voila! .48 AHI, 1.44 RDI, .48 FL. Feeling rested, I decided to put the FFM back on and strap it on rather tightly. This 2 hour session had an AHI of 0.00, RDI of 2.66, FL of 2.13 and RERA of .53. It was too short to reasonably evaluate sleep comfort or refreshment.

I could, of course, go back to the nasal gel pillow, chinstrap and tape and get along well. However, I don’t think I should give up on the FFM without giving it more time as it would be more comfortable and easier to deal with than the chinstrap.

Again, here are the posts from last night. I would appreciate your insights as to how to proceed. Thanks in advance. (The small sessions after the last major session were me trying humidity levels and strap adjustments while awake).

Thanks
Whipper

FIRST SESSION WITH FFM
SECOND SESSION WITH NASAL GEL PILLOW, CHINSTRAP AND TAPE
THIRD SESSION WITH TIGHTENED FFM

Bump.
I agree that the mask is the hardest part.
I went through a few before settling on my best fit.

I'm curious as to what you mean by "tighten" mask? The mask is not suppose to dig into your face. It should "float" on your face. That being said, you should be able to grab any area around the cushion, pull it, and lift it off your face with some resistance. What mask is the most comfortable for you? After many years of mask testing, I found 3 masks that I could wear. I eventually asked myself what mask was I most comfortable and liked the best? Occasionally I will use the other masks, but I quickly realize why I like the Total mask the best.

Sheriff

I like my mask to be tight enough that I can open my mouth as wide as possible without leaking but loose enough that I can slip 2 fingers under any of the straps. I have a routine I go thru each night when I put my mask on. I put the mask on and wear it high up on my nose, very close to my eyes. Make sure my silicone cushiony edges are tucked into that dip between my lower lip and chin. Then i open my mouth every direction possible. If no leaks, I slide the mask down into the right position. If I am getting leaks, I keep adjusting straps until the mask is right. Then slide the mask down.
Just keep playing with it till you find what works best for you.

The first session I wore the Dreamwear FFM loose; I would say that it aws "floating" on my face. The third session I tightened it considerably; but, it was not uncomfortable and did not leave any red marks. Of more concern to me is the mask size. I had read, and the therapist at the DME siad as well, that many people find the small frame to be of benefit. I agreed to start the FFM experience out with a small frame. I found my medium frame that I had always used with the nasal cushions to fit exactly as Resperonics suggests and to be comfortable as well. I think the small mask is too small however. I have always worn a medium nasal cushion with success. The small FFM has a cushion cut out under the nose much smaller than what is on the medium nasal cushion and I felt like I had to breath harder to get air. I will call the DME tomorrow to get a medium FFM. Until then I have gone back to the nasal gel cushion, chinstrap and mouth tape. Last night my AHI was 0.38, flow limitation 0.38 and RERA 0.38 for an RDI of 1.14. I can't expect better than that! My hope is to acheive similar success with the Dreamwear FFM (of course once I get the right size) because I think it will be more comfortable than also having to use a fairly tight chinstrap and mouth tape. Perhaps, it might require a slight change in pressure? Anyway, do you think I can reasonably expect success with the FFM? At least, if I can't I always can go back to the chinstrap and tape.

By the way, I wonder if the RERA numbers are reasonably accurate as measured by the Dreamstation. After all, it has no way of knowing if I woke up or not. I suppose the flow limitations are fairly accurate. With Dreamstation you do not get a flow rate graph; just a flow limitation "event" with the FL index calculated the same as an AHI event. Does anyone think I should only track AHI and not be too concerned with RDI?

Whipper wrote: ↑

Sun Apr 22, 2018 12:39 pm

With Dreamstation you do not get a flow rate graph; just a flow limitation "event" with the FL index calculated the same as an AHI event.

You should get a Flow Rate graph as long as the SD card is in the machine all night during use.
The Flow Rate graph data files aren't stored on the machine's internal memory and instead have to go directly to the SD card.

If your SD card is in the machine during the night and you aren't getting the Flow Rate graphs then something is wrong.
Make sure you haven't accidentally turned it off in SleepyHead first.

Unless the RDI is awfully high and/or I am waking often during the night I wouldn't worry about RDI.
If I am sleeping good...and feeling good during the day...and the AHI is reasonably low...I don't worry so much about the numbers.

My bad on the Flow Rate Graph from a Resperonics machine Pugsy. Of course I get a Flow Rate Graph as evidenced by my Sleepyhead attachments above. I just don't know exactly how to analyze it. That's why I pay attention to the Flow Limitation event markings and index. My understanding is that RDI is basically AHI plus Flow LImitation Index + RERA index. Am I correct? Your advice regarding not worrying about it if AHI is reasonably low and if sleep quality is decent is excellent Pugsy.
Thanks. I think I've focused on it too much and, besides based on my Resperonics FL and RERA indices added to my AHI historically I'm well under 5.0 (in fact usually below 2.0). By the way, how would a Resmed user be able to estimate RDI? And for that matter, how could anyone (except in a sleep lab) really know the RDI. It seems as if it's an estimate, at best, from Resperonics for both FL and RERA and a Resmed user would really have to analyze the graph to estimate FL. Does Resmed even try to report a RERA?

Whipper wrote: ↑

Sun Apr 22, 2018 2:04 pm

My understanding is that RDI is basically AHI plus Flow LImitation Index + RERA index. Am I correct?

Yep. Correct.

Whipper wrote: ↑

Sun Apr 22, 2018 2:04 pm

Does Resmed even try to report a RERA?

They do now but they haven't done it as long as Respironics has.

Whipper wrote: ↑

Sun Apr 22, 2018 2:04 pm

I get a Flow Rate Graph as evidenced by my Sleepyhead attachments above. I just don't know exactly how to analyze it.

You really can't do much analyzing of the flow rate graph until you zoom in on one of the flagged events and then you can see more stuff that is breath by breath and more meaningful. At the scale involved for the detailed report you initially see things are so crammed together you just can't tell much about the flow rate.

Over on the left side where you see the detailed tab and Events tab...click on the Events tab...then click on one of the flagged categories...that category will expand to show you the time each one of those events got flagged...click on one of them and the flow rate graph on the right side will zoom in and you can see the breaths easier.

Like this.


Jason has some good videos explaining what you can see using SleepyHead..have you seen them?
http://freecpapadvice.com/sleepyhead-free-software
Maybe help you understand a little more about what you are seeing. With time and experience it gets easier and less confusing.

Thanks so much Pugsy. I appreciate the help! I'll watch the video and follow your instructions.