please help confused.New info just added

sleepyjane wrote:Important new info-


If I understand it correctly, it never goes below 15 EPAP and 17 IPAP. The spread between the IPAP can be anywhere from 2 to 7 depending on what machine decides based on my breathing and such. It can go as high as 25 IPAP and 23 EPAP (but EPAP may be lower)

You understand it correctly. The UltraMirage Full Face is a good mask and that should also work fine for you.

I would accept the Bipap auto and make any further changes needed after you get it.

Snoredog wrote:

sleepyjane wrote:Important new info-


If I understand it correctly, it never goes below 15 EPAP and 17 IPAP. The spread between the IPAP can be anywhere from 2 to 7 depending on what machine decides based on my breathing and such. It can go as high as 25 IPAP and 23 EPAP (but EPAP may be lower)

you said--

You understand it correctly. The UltraMirage Full Face is a good mask and that should also work fine for you.

I would accept the Bipap auto and make any further changes needed after you get it.



Oh that is a relief that I finally understand it better. Does this sound like good setting, Snoredog, in light of the facts that I have hypopneas and such at 17 and I can't breath without suffocating under 15, and I was retaining CO2 in my lungs on old cpap pressure of 15 (through 20).

I greatly thank you for all the time you have invested in helping me, snoredog. I am rereading your posts trying to understand them better and if I run into questions I will post them soon.

I am happy that of the only two full full mask they carried, this one didn't seem to leak to much as the other one they had (fisherpykel hc 431 I think it was..leaked badly). Since I have a hard to fit smaller face, I am happy he brought the small as he initially was going to use the medium.

I think that is a good suggestion to wait a few days before using the full face mask to see how the new machines feels first and not change to much all at once.

Typical night for me with tape holding fairly well.
IPAP 20 / EPAP 8, PS set at 8, Bi-Flex set at 3.





Another typical night when tape held very well:



Example of EPAP/IPAP independently "doing their own thing":



Two nights when I tried using no tape at all. Lots of mouth breathing and IPAP activity:

Beautiful charts, Rested Gal. I can see exactly why you said PS max=8 is not a problem. I think you're probably right, now that I can take a closer look. Here's what I think I see:

Chart One- Quite a few small IPAP test increments (not based on sleep events). Also some IPAP pressure increments, triggering on lesser flow limitation events.

Chart Two- Similar to chart one, with one fleeting obstructive apnea thrown in.

Chart Three- Same elements mentioned in chart two, with the exception of that interesting apnea-related pressure response between hours one and two: the OA, EPAP pressure increment, and IPAP pressure decrement all occur at approximately the same time, shortly after which the OA being treated resolves. Shortly after the resolved OA disappears, an IPAP test increment occurs while EPAP is held steady. IPAP and EPAP both descend, based on both time and pressure-test criteria. However, shortly after IPAP and EPAP bottom out, a flow limitation occurs, which causes the very next IPAP pressure increment. The first OA pressure response on this chart was more algorithmically complex than the second OA occurence, simply because the preliminary (or "lead in") IPAP/EPAP spread was already greater in that first OA case (I still have to re-review the algorithm presentation Snoredog sent to see if my interpretation of OA-1 here is reasonable).

Charts Four and Five- Small leaks galore, but no "large leaks" by Respironics' definition. Because of the sheer quantity and flow-signal transitory nature of those small leaks, we just may see some occasional false-positive scoring of FL, H, and even S. Regardless, we still see what is clinically considered a good patient and machine response.

General Observations- PS=8 is "pressure-utilized" or realized somewhat sparingly by the algorithm, to implement designed pressure response strategies.

My Own Conclusion Based on Rested Gals' Charts- Setting PS max=3 or PS max=4 may be not only be unnecessary, but may actually subvert some of the designed features of this algorithm's unique BiLevel pressure strategy.

There just may be underlying central etiological nuances that factor into why manufacturer-tested patient-response patterns lent efficacy with patients spending significant (transitional and sustained) times with an IPAP/EPAP spread of 8 cm.

THANK YOU RESTED GAL FOR THE CHARTS!!!!!

Any thoughts Snoredog, Rested Gal, or others have relative to my comments are much appreciated.

More importantly, does any one have any more helpful thoughts or advice for SleepyJane? Sorry we got so sidetracked, SleepyJane. All my fault. .

rested gal questions in red


about your posted sheets

1.Is this what you get if you have the software?

2.Can you explain what some of it means.

3. Does it means the mask is leaking 30% of the time or maybe that means 30 times.

4. What do the number on the top right mean (90%)...

5. how do you know you are mouth breathing and so forth.

I am thinking of getting the software but not sure if I would know how to interpret it..

6.are there any websites explaining how to read the data or is it not too hard to understand.


about my new machine and settings

(been on bipap 3 years then cpap 12 years --all at too low settings apparently) so it is all new..I think I will not wear the full face mask until on a new machine a few days. This is what provider suggested..

1. is this a good idea or not?


Also, rested gal, can you please look at my new information and settings I just got today and tell me if it sounds good if I had hypopneas at 17, feel suffocated inf the machine is under 15 when I am awake and retain CO@ when I was on cpap 15.

2. Are these good settings..the doctor sent provider settings the machine could not do and this does not inspire confidence. The provider suggested the setting to him..yesterday they talked to doctor and they decided IPap 20 and EPAP10 but when I found out that the inhale pressure would only be 12 with this (or so I understand sleepdog's explanations), I told provider I would feel suffocated and to change it..with difficulty, they got doctor to change and they set it at (I think) maxIPAP 25 and min EPAP15, and I see it will start at IPAP17 and EPAP15 unless something happens. The ps is 7 and the biflex is 3.

Does this sound like a setting that is good..he was initially putting me on bipap18/14 until I got him to change machines and such?

that is fine, sws, wow, it is like learning a new language..I am so lost..are there books or website giving some tips on reading things like this or a primer for newbies.

I am assuming this info came from the car in the machine. I don't even understand how to tell if she had apneas. I wonder if it is worth getting the software..dos it come with explanations in how to read the data you download from card?

About how much is the software and reader..someone told me once but can't recall. I thought it was about $175..does this sound right?

sleepyjane wrote:that is fine, sws, wow, it is like learning a new language..I am so lost..are there books or website giving some tips on reading things like this or a primer for newbies.

I am assuming this info came from the car in the machine. I don't even understand how to tell if she had apneas. I wonder if it is worth getting the software..dos it come with explanations in how to read the data you download from card?

About how much is the software and reader..someone told me once but can't recall. I thought it was about $175..does this sound right?

Sleepyjane, that's a perfect analogy. It really is like learning a new language. There are plenty of experts here like Rested Gal and Snoredog who have been at this for years. Sometimes newcomers post their charts here to get help from the expert patients. As you can see in this thread, even the expert posters here sometime disagree about a few details. But so do the expert doctors and scientists for that matter.

You're also right about the card and reader. Here's a link to the one that goes with the Auto BiPAP model you and Rested Gal use:
https://www.cpap.com/productpage-bundle ... undle.html

Rested Gal and Snoredog are great resources on this forum. I think I had better turn you back over to them and the other Auto BiPAP experts who read this forum. You can also click on the yellow light bulb at the top of this page, and even the CPAP FAQ icon for all kinds of great preliminary information.
Good luck!

Here is "my" pirated markup of RG's 3/21 chart. Please excuse my graphics program, it is old and lame like I am (old version 5 of PaintShop Pro).

I marked up using the same colors as the pressure that handled the event in highlighted "boxes" All going from left to right as the time-line normally travels.

You can see the default "minimum" PS setting of 2cm in the beginning is maintained throughout the session. Where the PS setting gets broader it is using the "User" PS setting which can range from 3cm to 8cm. The maximum User PS value seen in this session is 6cm. It COULD have been set PS=8, but it wasn't seen in this chart, the maximum seen (if I counted the tics right is 6cm pressure seperation).

One question that comes to mind is: Would EPAP have come up and eliminated some or many of the FL's seen if PS was lower? That we don't know.
Why does the PS vary throughout the session? I would say that the algorithm does many things on a "timed" parameter, most depend if the event seen is also seen with a apnea such as a hypopnea and apnea together OR 2 hypopnea together. You can see from the chart, IF 2 events were close together they trigger a response, yet "single" events like a single OA doesn't appear to get any response from pressure. IF one of those 2 events is a VS, it may respond. Both pressure types can respond to VS.

What is difficult to see from these charts is how pressure responds to Hypopnea, only because there simply wasn't enough of them to see the response. I don't think we seen the PS=8 parameter fully exercised (as mentioned 6cm seperation was the maximum I seen from this chart).

Maybe we can find some other examples like Wally's and mark it up and discuss.

RG: Thanks for posting those. Say, you don't happen to have the bottom of one of those charts showing the "Daily Report Details" or "table"?

That would show everyone the IPAP and EPAP pressures used for the 3/21 chart where they can correlate it to the charts events and see what pressure handled which event.

Here is your chart (pirated by me) poorly marked up, there is no comment on Leak, I don't think leak had any influence on the outcome of this particular chart:


One question that should come about: Why didn't some of those events "trigger" a pressure increase? My guess is timing and what the algorithm was looking for (i.e. event terminated on its own or pressure was already high enough to handle it is one guess).

Note: From these charts there was no pushing-pulling seen because the PS=8 was not exercised. For example, if PS=4, then we would have seen EPAP "pulled" up by IPAP in response to a FL event. When OA events cease, pressure will want to fall over time, when the max PS is reached, EPAP can pull IPAP down with it. Pressures should never "crash" into each other because a 2cm delta separation is always maintained for the "minimum" separation. The Maximum PS delta is User settable (3-8cm).

I think these are pretty cool, from Respironics website, it seems those regular increase probes we see on RG's charts (on the green line) must be this Ptherapy mode in action:


Here's another one showing more clearer what events are handled by which:

sleepyjane wrote:1.Is this what you get if you have the software?

Yes, those graphs were from Encore Pro...from downloads of the Smart Card. There are several more pages in each report, but that particular graph is all I ever bother to look at. It has all the info I'm interested in seeing.

sleepyjane wrote:2.Can you explain what some of it means.

I'm not great at interpreting it. I usually just look at the AHI (want to see it be below 5.0, which it always is for me) and glance at the leak rate to see how whatever I was using (perhaps a different brand of tape or the mouthguard thingy) worked that night to prevent mouth breathing.

sleepyjane wrote:3. Does it means the mask is leaking 30% of the time or maybe that means 30 times.

Neither. The "average leak" number reflects escaping air measured in liters per minute. The number includes the normal air flow from the mask exhaust vent, plus the possibility of any/all of these things:
a. leaks from the mask cushion or the nasal pillows.
b. leaks from mouth or air breathing, when not wearing a full face mask.
c. leaks from loose hose connection or holes in the hose.
In other words...any place between machine and you where leaks might spring out.

sleepyjane wrote:4. What do the number on the top right mean (90%)...

The 90th percentile pressure means the machine used that pressure AND pressures BELOW that pressure 90% of the time. It doesn't mean that particular pressure itself was used 90% of the time.

sleepyjane wrote:5. how do you know you are mouth breathing and so forth.

You have to be your own detective. I know, from using the same mask for over a year, that I rarely get leaks from my mask. I also know that I mouthbreathe a lot in my sleep if I don't securely tape my lips closed. Sometimes when I wake up during the night or in the morning, I can feel that a corner or edge of the tape has worked loose enough for some air to escape. For the past three years I've been using tape almost every night. Rarely, I'll try sleeping without tape, as I did in the two last graph pictures. As the leak rate shows, I get a lot of leaks, presumably from mouth breathing.

As -SWS pointed out, those mouth leaks never reached the level of "Large Leak", and my AHI stayed low. But the many mouth air leaks I had lead to a very dry mouth in the morning and did cause the machine to have to use more pressure than it typically does for me. Untaped, I also tend to have more awakenings that I'm aware of during the night -- probably from the feel or sound of air gushing out my mouth, or the unpleasant feel of a dry mouth. So, I almost always put tape on as part of my "cpap routine."

sleepyjane wrote:I am thinking of getting the software but not sure if I would know how to interpret it..

It's pretty simple if, as is true for me, all you want to see is the AHI and leak rate. You could see that in the M machine's window without even using software. I'm just curious and want to see the actual graph, to see the ups and downs of what the pressure was doing, and what the leak line looks like from start to finish. I don't really analyze it closely at all. I'm not good at that. -SWS is great at that, so if I have a question, I rely on him to figure out "why this did that." But really, there's nothing much to question if the AHI is good and you wake up feeling refreshed. There's no need to worry about changes in the AHI or pressure from night to night.

It's normal for there to be nightly variations. There's no need to get hung up on, "OMG, the AHI was 3.0 this time when it was 0.2 the night before." As long as the AHI is under 5.0 there's no need to worry about variations in that, or in the pressure used.

sleepyjane wrote:]6.are there any websites explaining how to read the data or is it not too hard to understand.

No websites that I know of. It's not hard to understand, if all you're interested in knowing is what I mentioned that I look at...AHI and leak rate.

sleepyjane wrote:I think I will not wear the full face mask until on a new machine a few days. This is what provider suggested..
1. is this a good idea or not?

Your provider seems to have been guiding you well about the settings, so it wouldn't hurt to follow their guidance about using the mask you're already familiar with and used to, for the first few days with the new machine. Also wouldn't hurt to use the FF mask. Just whatever you want to do. You can always switch masks during the night, for that matter. It's nice to have more than one mask just in case one is not suiting you on some nights.

sleepyjane wrote:2. Are these good settings..the doctor sent provider settings the machine could not do and this does not inspire confidence. The provider suggested the setting to him..yesterday they talked to doctor and they decided IPap 20 and EPAP10 but when I found out that the inhale pressure would only be 12 with this (or so I understand sleepdog's explanations), I told provider I would feel suffocated and to change it..with difficulty, they got doctor to change and they set it at (I think) maxIPAP 25 and min EPAP15, and I see it will start at IPAP17 and EPAP15 unless something happens. The ps is 7 and the biflex is 3.
---
Does this sound like a setting that is good..he was initially putting me on bipap18/14 until I got him to change machines and such

Well, I personally would try the EPAP 10, IPAP 20 that the provider first suggested. The PS of 7 (I'd still go " 8 " on that, but 7 is ok) and bi-flex 3 settings sound fine.

I think you're worrying unduly about a need for "15" as an EPAP number for you with this particular machine, but the settings can always be changed to whatever suits you. Even though you needed 15 to feel like you were getting enough air on previous machines, I think you might be pleasantly surprised at how EPAP 10 / IPAP 20 would feel on the bipap auto, with bi-flex enabled and a PS of 7 or 8.

I wouldn't worry any more about the doctor's unfamiliarity with the machine settings. Sounds like he's willing to leave it up to you and the provider, and the provider seems to understand the machine settings.

Actually, I'd be thankful the doctor is not trying to bluff his way through the setup of a machine he's not familiar with, and is willing to let you and the provider work out what suits you.

I think you can just relax and enjoy the new experience. If you need some tweaks along the way, that's no problem. Sounds like you have a provider who will work with you to make it comfortable and effective for you. You'll do fine, Jane.

Snoredog wrote:Say, you don't happen to have the bottom of one of those charts showing the "Daily Report Details" or "table"?

Yeah, I can take a screen shot of that table. It's not something I ever bother to look at.

Snoredog wrote:That would show everyone the IPAP and EPAP pressures used for the 3/21 chart where they can correlate it to the charts events and see what pressure handled which event.

It's funny...I've never regarded that table to be of much use, so I never even glance at it.

Anyway, here it is:

rested gal wrote:

Snoredog wrote:Say, you don't happen to have the bottom of one of those charts showing the "Daily Report Details" or "table"?

Yeah, I can take a screen shot of that table. It's not something I ever bother to look at.

Snoredog wrote:That would show everyone the IPAP and EPAP pressures used for the 3/21 chart where they can correlate it to the charts events and see what pressure handled which event.

It's funny...I've never regarded that table to be of much use, so I never even glance at it.

Anyway, here it is:

Thank you RG!! Actually, I use that chart a lot. On a Bipap Auto I think it is even more important. It clearly shows you on the left colum (using the Legend) at the bottom which pressure (IPAP or EPAP) handles which type of event.

If you have a residual AHI=5.4 what do you change? If 4.3 of that AHI is HI, then well according to the chart you would need to increase IPAP pressure. But if the residual score remaining of that AHI was OA's, then you would need to increase EPAP. As you know this machine differs greatly from CPAP therapy. If you had residual FL's (like you) with a cpap you would simply increase pressure until they go away. Doesn't work that way on this machine although I guess eventually it would.

Next comes your 3/21 report I marked up showing which event triggered which pressure increase. That table report also tells me what those "Not Triggered" events were. If you look at the OA line you see 1.7 OA's were eliminated at the minimum 8cm EPAP pressure. Once EPAP moves UP from its minimum it becomes clear which event triggered which pressure (shown in blue). Those OA's seen met the criteria for a score but probably not severe enough for a pressure response.

It appears your OSA is made up mainly of FL's, interesting very few HI's, but I guess a lot of those are being eliminated with the Minimum pressure used.

Snoredog wrote:Here is your chart (pirated by me) poorly marked up, there is no comment on Leak, I don't think leak had any influence on the outcome of this particular chart...

One question that should come about: Why didn't some of those events "trigger" a pressure increase? My guess is timing and what the algorithm was looking for (i.e. event terminated on its own or pressure was already high enough to handle it is one guess).

I'm new at this, but don't you think the leaking would trigger the algorithm to handle things differently? It looks like when the leak graph is more flat, the pressures inceases and decreases more like one would expect given the events occuring...

I find leaks, even not large ones, cause me to have more events (big shocker huh?), and my APAP seems to wait for things to even out on the leak front before it goes jacking up the pressure. Anyway, this is all just guessing anyway since we don't exactly know the algorithm, I was just wondering if you had any particular reason to believe the mouth leaks didn't much affect the chart.

blarg wrote: I'm new at this, but don't you think the leaking would trigger the algorithm to handle things differently? It looks like when the leak graph is more flat, the pressures inceases and decreases more like one would expect given the events occuring...

I find leaks, even not large ones, cause me to have more events (big shocker huh?), and my APAP seems to wait for things to even out on the leak front before it goes jacking up the pressure. Anyway, this is all just guessing anyway since we don't exactly know the algorithm, I was just wondering if you had any particular reason to believe the mouth leaks didn't much affect the chart.

Yep I've seen that happen. How the Remstar handles leak: in the persistence of large leaks, particularly when the patient's breaths have small tidal volumes, could potentially induce false apnea and hypopnea detection. Therefore, the Bipap Auto moitors the patient's flow over several minutes.

The patient's flow is compared to "expected leak." Expected leak is a value determined through testing of various mask and tubing configurations. As the pressure is increased, the "expected leak" also increases.

The algorithm operates normally while the patient's flow is less than two times the expected leak. A leak is detected when Baseline Flow increases to more than 2 times the "expected leak".

This increased flow is considered to be in "large leak" if the threshold is exceeded longer than 1.5 minutes.

The Bipap Auto system responds to the "large leak" by dropping the IPAP pressure 1cm every 2 minutes until the "large leak" condition is cleared.

As the IPAP pressure is dropped, the "expected leak" also drops.

A "large leak" condition is considered cleared when the leak drops below the 2x "expected leak" for 1.5 minutes.

Your Auto should function similarly, but again it monitors over several minutes before doing anything. If it impedes the ability of the algorithm to function normally, it will put a heavy black tic at the top of the Leak Chart during those times.

As for RG's charts? I didn't comment because I only glanced at that data as I didn't see any large black tics indicating a LL to show me where the machine performed any response to them.