Results Day 1-12

[Tallen234]

Ok, I know a number of you have been helping me out on my therapy (most of you telling me to slow down!). So, here are my results from Days 1-12. I believe I have gotten used to the mask and can sleep through the night with only one or two awakenings. However, my quality of sleep feels much worse than before I started the therapy. My average AHI is 22.8. According to my sleep study, they titatrated me to 13, but recommended 14 or 15. The sleep doc set my autoset at 7 to 14. I am strongly considering running the Autoset in CPAP mode at 14 (according to the titration study) to see how that works. This is getting frustrating as there does not appear to be any rhyme or reason to my results. For example, when I have a huge leak event, my AHI is not much different from when I have almost no leaks. My AI seem all over the board .7 to 6.9. My HI seems "consistently" high (14 to 25).

Starting High Pressure Pressure Leak AHI AI HI
7 14 8 0.36 14.5 0.7 13.8
7 14 8.8 0.34 20.8 4.1 16.7
8 14 9.6 0.46 31.9 6.9 25
8 14 9.4 0.06 30 7 23
9.4 15 10.2 0.08 22.3 3.6 18.7
10.4 16 10.8 0.24 20.7 3 17.7
7 15 9 0.4 26.1 6.5 19.6
7 15 9 0.1 24.7 3.3 21.4
7 15 8.4 0.14 22.3 0.8 21.5
7 15 8.8 0.06 16.6 2.6 14
7 15 9 0.38 22.5 3.9 18.6
7 15 8.8 0.32 21.5 4.2 17.3

So, I am at a loss. Any insights????

Thanks

[jnk]

Now that your leak is down, your numbers mean more.

Your AI is low consistently, so that is good. AI is the prime thing. Especially on a ResMed.

With your machine, you can't get too concerned about occasionally high HI and AHI. ResMed scores any slight limitation of air flow as an hypopnea. You can experiment to bring those numbers down, within reason, eventually. But any shallow breath, which naturally occurs when transitioning between sleep levels, is gonna show up, so the nights where you transition a lot will have high AHI.

If I were you, I might choose to go ahead and raise my pressure to 13-15 tonight and see what happens for a week. I might then compare that whole week to the week I spent at 7-15. If I got a higher AI, that might mean I was likely getting some pressure-induced central apneas (no big deal, but no reason to induce them, ya know). If I got a lower AHI, that might tell me that "higher than 7-15" is at least the right direction to go. I would consider my doing that safe since I had been titrated at 13 straight CPAP. But that's only what I would do. The more experienced ones here would likely have an approach based on their experience.

Give it time as far as feeling better. Your body/mind/brain/nervous system/hormone system all have to get used to what is happening.

Meantime, research as much as you can on "sleep hygiene." Getting a full 8 hours in the right way should accelerate the benefits of PAP therapy.

No need to feel at a loss, unless you just want to feel that way. Keep taking it slow, and be patient on the results. One way or the other, you WILL get there.

jeff

[gasp]

Ok, I know a number of you have been helping me out on my therapy (most of you telling me to slow down!). So, here are my results from Days 1-12. I believe I have gotten used to the mask and can sleep through the night with only one or two awakenings. However, my quality of sleep feels much worse than before I started the therapy. . . .

I believe it's all about perception. I believe when we start therapy we are hyper aware of the mask and air blowing at us. This awareness helps us to perceive we are getting less sleep. When not on therapy, we perceived that we were sleeping, when actually our bodies were having damaging and dangerous periods of time when we didn't breath. When you read your report from the sleep study, did you wonder how you lived through not breathing for such extended amounts of time that happened so frequently?

I'd rather wake up often getting used to therapy than sleep through dying slowly. I hope you feel more rested soon. It took me several months to get used to all the equipment and start to feel rested. Hang in there!

[bdp522]

This is getting frustrating as there does not appear to be any rhyme or reason to my results. For example, when I have a huge leak event, my AHI is not much different from when I have almost no leaks.

When leaks are too high the data is unreliable. Looks like you want to keep the leak under .2, as close to 0.0 as you can get.

I think using the titrated pressure of 13 as a starting point is reasonable.If you're gonna do cpap, 13 is a good place to start for a week. If you want to do apap, 11 - 15 sounds ok to me.

It may be taking the machine too long to respond to the events, set as it is. If you raise the lower pressure it will get to the needed pressure sooner. Remember to make one change at a time and to stick with it for a week before changing anything else.

Brenda

[Tallen234]

Thanks guys. I will try APAP from 12-15 for a week. Hopefully by that time I will get the card reader and software.

Another thing I found strange when "messing" with my pressuring during the first week, my 95% pressure increased each time I increased the starting pressure.

7 -> 8.8
8 -> 9.6
9.4 -> 10.2
10.4 -> 10.8

I will stick with it. I am merely a bit disappointed with the delay. My father in law felt a significant change almost immediately.

[Snoredog]

What you want to do is:

1. Find your mask intentional flow/leak rate for your 95% pressure. Your machine displays leak in Liters per second (L/s).
The flow chart that came with your mask will display the intentional leak rate in Liters per Minute (L/m). So if your machine displays .08 leak and you want to know how that compares to what the mask flow chart is supposed to be, you multiply the LCD reading x 60 to get the Liters per Minute. If you exceed what the mask flow chart for the mask says you are developing leak either from where the cushion meets your skin or you are mouth breathing. Mask leak plays an import role on the AHI information displayed on the machine. So if you get an unusually higher AHI and leak is high, that is probably why. You can only trust the information from the LCD if your leak is within normal limits.

2. You have Minimum and Maximum pressure. At this point there is NO reason to limit the high end pressure, you don't want the machine running into any Maximum imposed limit unless you know of a valid reason to limit it. So put your Maximum pressure up high enough or at the maximum of 20 cm. You had one night at 16 cm, so I would put it at 20 cm and not worry about it.

3. Next, If you want to make intelligent decisions on weather or not you should increase your pressure, you do so by observing the Apnea Index (AI). The Hypopnea Index (HI) means nothing and is secondary to the AI setting. You first adjust Minimum pressure to get AI down to 1 (AI=1). Once you get AI down to 1, you start watching where HI is. If HI is greater than 5, you increase the Minimum by .5 pressure until it drops closer to zero, AI should then further drop to .8 or .6 and HI should drop very fast. Once you get HI down below 5 you are good to go. If you SUM up the count of AI and HI you have your AHI score. AHI should be under 5. If you keep your leak under control you may even be able to get it down to zero, but that is usually impossible to maintain night after night.

4. Any pressure you land at try and judge how you feel, feeling better the next day always takes precedence over any AHI value see.

So if you make changes with your pressure, you do so by increasing the Minimum pressure over several nights while observing the AI index and leak. Leak always has to be within Normal limits for the AI and HI data to be accurate. If you are using a non-Resmed mask, you need to make sure you select "Std" from the menu or if it is a Full Face mask, select Full or Ultra Full.

Note: use of non-Resmed mask may throw off the leak scoring from the LCD (i.e. **** rating system etc.), in that case you look at actual leak values in L/s.

[Tallen234]

Thank you for the detailed response, I really appreciate it.

The literature that came with my mask (F&P 431) states that at 7 the exhaust flow is 32 l/m and at 9 the exhaust is 37 L/min.

What frustrates me is that the pressures that I have used aren't affecting my AI. For example,

At 8.8, AI was 4.1
At 9.6 AI was 6.9
At 10.2 AI was 3.6
At 10.8 AI was 3.0
At 9.4 it was 7
At 8.4 it was .8
At 9.0 it was 3.9
At 8.8 it was 4.2

Last night, I had my APAP set at 12-15. My results were 12 .22 23.4 6.6 16.8. So at 12 my AI was 6.6.

My sleep quality is worse than before xPAP.

It seems the sleep tech also had a difficult time titrating me:

The patient was initially started on CPAP at 5 cm of water pressure and was gradually titrated up to 11cm. Initially at 11cm the patient did well, though after nearly an hour of consolidated sleep the patient had an awakening. This was followed by reappearance of central apneas and hyopneas, because of which CPAP pressures were gradually titrated up to 13 cm. At the highest pressure achieved initially, the patient again did not have any breathing events, though toward the tail end of the study scattered hyponeas and Respiratory Effort-Related Arousals as well as central apneas were seen. The central apneas would present after the patient had arousals. Thus it appears that the patient was slightly under-titrated. He did not have much in the form of air leak.....

Recommendations

Based on the findings of the study, the patient clearly benefits from positive airway pressure therapy. At this time, CPAP pressures of 14 to 15cm would be recommended along with Respironics Comfort Fusion nasal CPAP mask, a chin strap as well as heated humidification.

[jnk]

After reading that part of your sleep study report and hearing about your troubles, I gotta say that I would ask my doc whether I should be titrated for bilevel. Seems to me the tech was subtly hinting that maybe that would have been tried in your case had he/she had more time to try things after those later events occurred. The phrases "tail end of the study," "under-titrated," and "at this time" can be code phrases in certain situations. I might even gently refer to those phrases when asking the doc about whether a bilevel titration should be considered for me.

Other than that, here are some things to think about.

Are you sleeping on your side? That can help.

Use the ramp feature every time you wake up so that the events that occur as you fall asleep don't get scored.

I still think that your auto would be better able to do it's job with a mask it "recognizes," as unpopular a notion as that is. You have other masks coming, if I remember, right?

It is my understanding that many people have some centrals as the body gets used to PAP. Many people starting out wake up a lot and don't get good sleep for a few weeks because of the process of the body learning that the big chunk of plastic against the face and the funny pressurized-air sensation are not threats to its existence.

As for sleep quality, it depends on your definition, I guess. If the machine is reducing the number of events, your sleep is better, even if your sleep is fitful and you feel pretty lousy for a while.

For some of us with severe OSA, we are never going to get our AHI down near 5, no matter what pressure or machine we use. That's OK, though. If the machine gives us marked improvement over the long haul, it can still be considered successful treatment.

But if you are continuing to feel symptoms of SDB, and especially if you feel your symptoms seem to be getting worse instead of better, that is definitely something to tell your sleep doc so that other machines, such as a bilevel or autobilevel, can be considered for you.

I would welcome opinions that differ from mine on any of the points above.