CPAP can I help it along?

You can't do much about eliminating REM nor do we really want to. Our bodies need all the sleep stages in the nice normal progression and in normal amounts for the restorative powers of sleep to work their magic.

The 2 main players in the bilevel market are Respironics and ResMed. I wouldn't even look at any other brand if it were me.

I would suggest the auto adjusting model and not the fixed bilevel model.
Bilevels will go to 25...actually some will go to 30 but those are specialty machine for very special needs like COPD lung stuff.

I don't know where you want to look but I usually suggest look at secondwindcpap.com for international cpap users. Fair prices, honest service and good people. They won't require a RX either.

So if looking at bilevel models (and there is more than one kind) these are what I would look at.
Resmed....AirCurve 10 Vauto
Respironics....DreamStation BiPap Auto

Now there is the option of the slightly older model that the AirCurve and DreamStation replaced and will be less expensive
Resmed....S9 VAuto
Respiraonics...Phillips Respironics System One 60 series BiPap Auto.

Of the 2 brands....get the ResMed if you can afford it. It's not hugely more expensive but it does cost a little more.
I have used both brands in both the cpap/apap models and the bilevel models.
I think ResMed is preferable especially in your situation. I think the ResMed algorithm might let you get by with a wee bit less pressure at times because it can respond faster. I think you will get good therapy faster with ResMed. They both do a good job but they go about it slightly differently.

So check out those models and then come back with your questions as I am sure you will have some.
https://www.secondwindcpap.com/

And I am going to give you the links to the product pages at cpap.com because they explain the product in more detail
https://www.cpap.com/productpage/resmed ... chine.html
https://www.cpap.com/productpage/pr-dre ... chine.html

The ResMed has the humidifier built in...the Respironics you have to buy the humidifier separately so an additional purchase.

There are some minor advantages with the new models vs discontinued prior model but not deal breakers but mainly in some comfort features. When they did the model change they didn't change the algorithm for how the machines go about doing their job.

About REM worse OSA if that is what is going on with you. It's common. I have it. In non REM sleep my AHI was around 12 but in REM it was 53 on my sleep studies. I sometimes need 6 to 8 cm more pressure in what appears to be REM. It's fairly easy to spot when not treated optimally.....clusters of OAs happening at about the same time I would expect to be having REM.
It's why I prefer auto adjusting model machines. I don't want to use the higher pressures all night....just the part of the night that I need the higher pressures.

I can use fixed pressure models but I have to make some compromises in terms of pressure and therapy if I do.

Hello again DomP,

The two main manufacturers who supply machines to the NHS are Philips Respironics UK and ResMed UK. Each foundation trust hospital has its own policy, and makes its own deal with the manufacturers. FT hospitals tend to bulk-buy from one or the other - rarely both.

Both of these mananufacturers sell proprietary software to the sleep-medicine departments so that the data from their machines can be read. They charge quite a bit for it - and obviously, the ResMed software isn't designed to read PR data, and vice versa.

(And of course, NHS professionals do not use Sleepyhead for reading data - because that's shareware, and written by a third-party programmer - which puts using it on a different legal basis - even though in many ways, it's a much more user-friendly bit of software.)

So, if you're buying your own machine, there's an advantage in buying the same brand as your sleep-medicine department has standardised on. If you continue to be a patient with them, they can read your data.

And from the machine you've indicated you're using, it's clear St George's has standardized on Philips Respironics.

Now, the kind of machine which can go to pressures greater than 20 cm does so because it's what's called a 'bi-level'. It's designed to use one pressure for each inhale, and a markedly-different, lesser pressure for each exhale.

For marketing reasons, Philips Respironics called their version of bi-level 'BiPAP' - but that is their trade-mark. The generic name is still 'bi-level'.

The PR Dreamstation range has: a fixed-level bi-level; an auto-adjusting bi-level; and an ASV. (An ASV looks are each single breath and calculates what to do. It can be set to operate in other modes.)

If it comes to it, I'd suggest for you the Dreamstation BiPAP Auto - it gives more options than the fixed bi-level, but costs a good bit less than the very-expensive ASV. The BiPAP Auto can be had in the US for $1,639. You'd have to ask Philips Respironics UK what the price is here. Dialing from within the UK, they're on 0800 130 0844.

Follow-up after reading Pugsy's post (I hadn't registered there was a page 3 before I wrote mine):

The Dreamstation is the latest range from Philips Respironics. The previous range was called the '60s series' - because it had model numbers 461, 561, 761, and 961.

And yes, you can buy an older 60s series auto bi-level. It's just a good as the Dreamstation.

And if you buy 'second-user' - preferably with low hours - you can save some money.

Unfortunately, the second-user market in the UK is nowhere near as developed (yet) as it is in the US.

If you buy second-user from the US - say, from the above-mentioned secondwindcpap.com - you will pay something to HM Revenue and Customs. Once you give me a price, I can explain to you how much in detail - but for the moment I'll just say: it is a factor.

I suggested going with a PR auto bi-level machine because I assumed that you would want to stay a patient within the NHS. And you would want stay with St George's because you're already with them. And because you want to be OK'd to the DVLA - and the Agency prefers that OK to come from someone at hospital consultant level.

And at the same time, I bow to Pugsy's expertise - she has used both brands of bi-level, and I haven't. And she definitely knows what she's talking about.

If you were to go with the ResMed auto bi-level - and St George's can't or won't handle that - you can ask your GP to refer you to the sleep-medicine department at another London hospital.

There are at least two that I know of in the Greater London area which have standardized on ResMed, and have their software.

The choices are yours.

Wow, such great info, thank you both. I'll be calling my clinician tomorrow once I have (as far as possible) ruled out the REM. But, by the sounds of Pugsy's comments around the clusters, it does sound likely that REM could be a cause.

Going to look at those links now. Thank you both.

Morning (at least on my side of the pond) Rick,

Medical equipment should be exempt from any duties. I have sent machines to London along with knowing a couple of people who bought from secondwind and they didn't have any extra duty fees. Best to check with appropriate authorities of course but when I shipped all I had to do was put a disclaimer about per whatever regulation (I forget the number) medical equipment and exempt from extra duties or fees.
Now if things have changed since I shipped to the UK...and there are fees then one would have to do the math and figure out if the savings in dollars buying from some place like secondwind was worth it.

Now about Respironics vs ResMed and the fact that his hospital/clinic probably has the Respironics software. You know me...I don't give a hoot about helping the NHS do their job. I only care about the patient getting the best possible therapy and I tend to think that the doctors need to accommodate patients and not the patients accommodate the doctors. I know in real life it might not work out that way but it doesn't stop me from thinking that way.

We can get Dom the ResScan software...so there's nothing stopping him from bringing his own reports to his doctors if they don't want to get the ResScan software.

Having used both brands of bilevels...and I still own a PR S1 760....the ResMed algorithm at the higher pressures I think is a bit better.
I always have to use higher minimums with Respironics than I have to use with ResMed. Plus I spend less time at the higher pressures during REM on the ResMed than I do on the Respironics. Less time at higher pressures means less chance of the usual problems associated with higher pressures like in comfort or aerophagia.

Respironics makes a good machine (or I wouldn't have one myself) but in some situations I do think that ResMed might be the better of the two choices. I think that when people are having to use minimum pressures in the teens qualifies for that situation.
The ResMed is less noisy at the higher pressures too.

If his clinic doesn't have and doesn't want to get ResScan....there is no reason to get a Respironics just to make it easy on the the clinic.
He can get ResScan and take his own reports to the clinic for follow up.
Now if he wants to go ahead and stick with Respironics maybe from the cost aspect that's fine too. It's not a crap machine by any means but if he just wants to make it easy on the clinic and that's the only reason he might lean towards Respironics...we can get him ResScan and he can do that work for them. Won't even have to change to a different clinic.

I don't like choices! Especially ones I don't fully understand or have experience in. I always feel like I have made a mistake in my choice. I definitely hear what you are saying about ResMed being the better of the two for the reasons mentioned, but I will also be subject to what the NHS have to say on this matter. Before making a choice I will speak again with my GP to see if a referral elsewhere is possible where they support the ResMed machines. I'm not really bothered who I see, as long as it's convenient and the equipment chosen is right. if that means ruling out DS and moving from NHS St Georges, to another NHS hospital, then fine. My private health insurance doesn't cover OSA, so it's NHS all the way for me.

I'm going to be making a wall of stuff behind me tonight so that I can try stay on my side, so I at least can find out if REM is a factor, or if a better machine would be the answer. Things are fairly tight money wise, but I see the importance of finding the money for this, especially as it is long term.

Plan of action is now check morning readings. Contact my clinician and discuss ResMed, BiPAP and Respironics. I will be reiterating what I have learned from you both in the hope she sees that the current machine is possibly not good enough. If they are going to supply a BiPAP for me, I probably won't get my own or at least just yet. Who knows with the NHS right now, no point second guessing at this stage. I will however have a look and compare some prices to the machines here and over there.

I know of one guy in the UK where NHS gave him a bilevel...the wrong bilevel IMHO but a bilevel none the less.
It is a Respironics System One...he has had it a couple of years. So they will supply them if need is proven. Now what they need for proof of need...I have no idea. So they will do it but probably not without a few hurdles.

If they will give you a Respironics bilevel auto (not the fixed) you will do well with it. It's still a good machine...there's a reason I still have one myself. It's designated as a travel/back up/spare machine though. It's is not a crap machine by any means.

I am leaning toward supine sleeping being the primary culprit for you. Mainly because REM stage sleep doesn't typically last as long as your clusters are happening.

The choices part...if it comes to that. We can chat more about the little subtle differences in brands if you wish so you can be more comfortable with any choice you might make.
But hey....maybe you won't have to make a choice and the NHS will give you an auto bilevel and the Respironics is still a very good machine. My main thought for you is that the response being quicker might let you get by with some slightly lower pressures but I can't guarantee it. It might not work out the same way for you that it does for me.

Here's my last 2 nights, one with 19 Auto min (last night)

I take it the green blobs are the clusters you refer too? When I hover them they are between 2 and 4 minutes. Does that mean laboured breathing that is not supported enough for that time?

Also, on the OA line, what are the numbers in brackets?

Not to nit pick - you are already getting good input from others and seem to be paying close attention. The single suggestion I would make is to choose words rather than pictures for the equipment in your profile. A tiny picture of a machine or mask that looks exactly like half a dozen or more other machines/masks makes it incumbent on the viewer to have to do something to understand what exactly you are using. Words eliminate that possible misinterpretation. Other than that, keep on the leading edge of the wave and it will carry you far.

The green blobs are periodic breathing which is nothing more than a waxing and waning of the air flow that lasts at least 2 minutes.
Not a big deal unless we see large chunks of it with a bunch of centrals in the middle of it.

The clusters I speak of are the times when the OAs are densely flagged within a time frame.
Example between 4:30 and 5:00 on the Monday report....which that one might be REM...30 minutes and in the wee hours of the morning were we have more REM. Might also be when you were on your back...might also be when you were on your back and in REM.
We can make educated guesses but they only go so far.

It's obvious the machine wanted to go higher than 20 during that cluster but it couldn't. How much higher we have no way of knowing until the machine can go where it wants to go and the clusters don't happen.

The Tues report...the first 2 smaller clusters might be REM...the first one is shorter and in about the time frame we would expect the first REM stage to happen. The second cluster...a little longer duration and might be REM related.
The third cluster and by far the biggest starting at 5:15 to 6:00....that's 45 minutes for a REM if we blame REM and I just don't know if REM would last that long but it might especially in those wee hours of the morning.
The way REM progresses is the first REM is relatively briefly and comes on at around 90 to 120 minutes after sleep onset.
Then as the night goes on the REM stages come a little more frequently and with each stage the duration increases a little.

So maybe these are more REM related than supine related. The timing and duration would be appropriate.
You will know more once you can stay on your side for sure. That's what I did....I built a wall that wouldn't move and I slept on one side and woke up in same position and I still saw the clusters so I knew that it was REM. Plus my in lab sleep study documented my OSA being worse in REM. At that point I quite worrying about what might be going on when I was on my back because REM was going to happen anyway and I might as well have a machine set to take care of whatever happened.
We can't really limit REM except maybe with certain meds and you don't want to go there. Those meds are bad news anyway.
Better to just get a machine that can go to wherever it needs to go whenever it needs to go for whatever reason and be done with it.

Thank you for the explanation. I've now found the help manual so I hopefully won't be asking silly questions that you've no doubt answer a gazzilion times...hopefully.

Apart from OA are there any other areas you suggest I have a read about?

There's some good basic information in the CPAP Wiki at the top of the forum page...the little light bulb thing.
Some of it is a bit outdated but the basics of anything is always there.

If you want to learn about sleep stages you can Google "sleep stages" and start reading and also looking at the hypnograms you can get an idea when REM usually happens.

There's a good video here about sleep disordered breathing if you haven't seen it
https://www.youtube.com/watch?v=-gie2dh ... e=youtu.be

Hello again, DomP.

Wrt to your next conversation with the consultant: Perhaps I can add that the policy in sleep-medicine departments across the UK has been moving in the direction of more-flexible, more-capable machines for some time now. Not uniformly, but in enough places for an experienced observer to notice.

Ten years ago, almost all machines issued by the NHS were fixed-pressure ones. This was partly because that was what the NICE guidelines said was the recommendation, but also because of the cost. They were cheaper.

So when I first turned up at Gloucestershire Royal Hospital back then, that was what patients were routinely being issued with - and I was an oddity - not just because I already had my own machine, but it was an auto, a PR System One 551. A couple of the staff had never seen one of those before. So I got to give them the guided tour.

What has happened since is that the staff in some sleep-medicine departments have realised the benefits of having more treatment options to draw on than the NICE-guidelines allow. So the issuing of an auto-adjusting machine has grown, and is now standard in quite a few NHS sleep-medicine departments across the country. For example, you have one.

That just wouldn't have happened 10 years ago.

And I'm seeing reports of NHS patients being issued with the more expensive bi-level machines - if their clinical need points that way.

So the cost-benefit argument is already taking place. Plus, the manufacturers can see the trend - and they don't want to be left out. So they will no doubt be offering the higher-end machines to the NHS at quite a healthy discount - provided the sleep-medicine department buys a few thousand units at a time.

And of course, some of the cost is being passed down to the clinical commissioning groups. They're the ones who pay the hospital sleep-medicine department a fee for every patient year of treatment.

So it may be, DomP, that your consultant can find you a bi-level within the system - and for good, clinical reasons.

Do let us know how you get on.

RB.