Pressures all over the place. Now what do I do?

[CROWPAT]

Everyone here has done their best to help, but I am getting no where.

I tried 7-20, 7-12, 8.5-14, 9-15 and several other pressures. I kept it on each one for 4-7 days to get better data.

90% pressures varied from 6.9 to 13.8. When the upper limit was at 20 90% pressures were 6.9-12.73. Then I lowered the upper limit to 13-14 the 90% pressures were9.4 to 13.8.

The average of the 90% pressures over all of the various settings was around 11.

OAI was best at 7-20 and AHI hovered around 5, but the snore index was around 50 there. At 7-12 the AHI was about 5 but the snores dropped dramatically.

OAI went up whenever the floor was over 7 and snores went was down to less than 5 at any of those pressures.

Any recommendations? I have to leave Saturday for a week in South America and would sure like to be more alert than usual on that trip.

Pat

[Handgunner45]

I think you need to look at your leak rate to determine if there might be a correlation between the leakage and a higher 90% pressure. I can also tell you that there are many other factors that could affect your pressure. My AHI will vary from night to night and I would assume that my pressure would also (I am on straight CPAP). My numbers will change with the amount of exercise I get in the evening, how late I eat supper, weather or not I have a drink (alcohol) in the evening, how hot or cool the room is.....etc......

Changes in your upper limit should not have any effect on 90% pressure unless you set it to low so that it is maxing out to try to prevent events.

Have you tried straight CPAP. You may be one that APAP will not work effectively for. Sounds like you could set to 12cm and monitor that to see what happens with AHI. Then (after 4-7 days) adjust to see what the effects might be.

Just what I think I would try!!!!!!
Its worth just what it cost you.

[roztom]

Wow, you sure seem to be all over the place with that.

Where were you titrated at?

Also if it were me, I would start at the low end maybe 6 or 7 (subj to titration) and go in 1cm range steps. ex 6-7, 7-8, 8-9 etc.

Give it maybe 4-5 nights at each increment and you will see how your AHI does. Then you can make a determination of what range is best for you.

I have an APAP but I get the best treatment at either 5-6cm or 9cm. GO figure. Inbetween 6-9 my AHI goes off the chart and at 10-11 it shoots up.

My point is that an APAP may not be the best treatment for you. Symptoms respond differently at different pressure. In my case it is counter-intuitive that pressures inbetween are less effective than the higher pressure but that is what the data says.

THeory is that higher pressure act as a protection against OSA. In my case that is NOT what happens - my OSA goes up and they are not Centrals, even weirder.

The reason I'm mentioning all this to you is that this is not necessarily a one size fits all therapy and also it can be counter intuitive.

I suggest you monitor your AHI at various pressures and find your sweet spot. Currently you are jumping all over the board. I don't think you can draw any conclusions from the ranges you have been trying.

Best,

Tom

[-SWS]

Theory is that higher pressure act as a protection against OSA. In my case that is NOT what happens - my OSA goes up and they are not Centrals, even weirder.

If that statement about centrals is derived from a PSG, then it may be valid. However, if that statement is derived from how many events happen to occur in the "NR" category, then there is some room for error. The "NR" category simply acts as a repository for events that did not resolve within three pressure increments above 8 cm (with unlimited increments allowed below 8 cm). For some patients with long-duration central apneas the "NR" category serves as a better-than-fair central apnea indicator.

For other patients with central apneas that are either of short or fleeting duration (i.e. central apneas disappearing in less than that three-pressure-increment time window), that "NR" category's apnea-detection sensitivity score would drop off considerably.

The "NR" category's central apnea specificity score would be negatively impacted by the number of obstructive apneas a patient might have that will not clear within three pressure increment attempts above 8 cm. The "NR" category is not an excellent indicator of central events in my own opinion. But I do love my Remstar Auto none the less!

[Goofproof]

Like I say,"Tighten the leash on that puppy.". I just got my new Remstar APAP w/ C-Flex. So I set out to play with it. I had been running sucessfully at 15.5 CM, AHI under 1.5 for months.

So I set the new toy at 12 CM low and 16 CM high, first night AHI 0.0, I thought this is too good to be true, and it was The next night was worse, so I set it wider, they got even worse, so I set it 10 to 17, and it got higher every night.

I set it back on the leash, 13 cmto 16 cm, and AHI has been under 0.5 for 3 nights. Leash that puppy to your nightstand, and control all leaks, even the one that come out in De-Nile. Jim

[harikarishimari]

Your pressures are "all over the place" because your pressure requirements are "all over the place". That is, YOU are "all over the place". You may be one who tosses and turns, and has different pressure requirements depending on whether you are on your side or on your back, or wherever. Some people have allergies that flare up and affect the pressure requirements. Or a cold. Or you drank too much water, or too little.

Be THANKFUL you have an APAP that is able to respond to your widely variable pressure requirements. I would suggest leave considerable latitude for the machine to respond, say +/- 2cm from your average titration = 9-13, or +/- 3cm = 8-14.

There is no requirement that your pressures "stay put" as some people suggest, for no apparent reason. And there is no point in forcing it to "stay put" by switching to straight CPAP mode. That would be the opposite of what you should do. The only requirement is that you keep BREATHING. You sound like the type of person for whom APAP was invented, with variable pressure requirements from night to night and hour to hour. Be thankful. Your AHI is down around 5 or less, be more thankful. That is basically "normal". A few AHI points plus or minus is of no consequence.

The fact that your pressures are all over the map suggests that your SS titration is probably meaningless. Just throw a dart, depending on which night you were studied. I would put more faith in the cumulative average over many nights, like the APAP will do for you automatically. You should be in good shape for traveling, just give the machine enough elbow room for doing its job. I too am on the road most of the time with my job, (or in the air). My pressure requirements are "all over the map". Just like me.

-HKS

[CROWPAT]

Thanks, Roztom, Jim, Tom, and Handgunner45.

My NR apnea are near zero at all pressures.
Most apneas occur near the start and end of a night's sleep. I am 100% compliant at 8 hours a night.
Apnea events are near constant at about 12 seconds each.
Leaks are not an issue for me.
FLI varies but is usually about .60.

I was on 14 cm for about 5 years and felt crummy. That is why I went to APAP.

My APAP maxes at 15 or so even if set for 7-20 so upper limit is not a problem.

Hope the above gave you something more to consider while advising me what to do.

Pat

[Goofproof]

The problem I've found, is APAP likes to hunt problems, even if they aren't big problems. While it trying to fix a small problem, it creates a larger problem. Example. "I think I hear a Snore, I'll bump the pressure a little. That results in a little leak, the leak triggers more snoring, so the pressure goes up higher. finally the machine pressure goes up, so high you stop snoring, but by then, the leaking is a factor.

By narrowing the range, to a little higher than you need for the low setting, you spend more mintutes at the lower pressure, and it can still move more quickly to the higher pressure, if you need it. That's when the APAP is doing it's best work for you, you want the lowest pressure you can, for the longest time, and still be able to cover your problems that require a higher pressure. Jim

[Darth Vader Look]

I was on 14 cm for about 5 years and felt crummy. That is why I went to APAP.

My APAP maxes at 15 or so even if set for 7-20 so upper limit is not a problem.

My suggestion is to set your span narrower to say 12 to 16 cms and see how 6 days at this span crunch out data wise. You can have the span on an APAP set too wide which could result in missed apnea events. Your AHI seems to be in the okay region (5) but it still would be worth bringing it down to a lower level. You may even want to play around with the C-flex setting or even turning it right off.

With mask leaks, you will get them with a full face mask. Best way to eliminate them is by setting the pressure to your highest level (in my suggestion that would be 16 cms APAP set to CPAP) and adjust the mask for leakage here while lying down. If necessary use moleskin. Don't forget to reset the APAP back into APAP mode once you have your leaks resolved.

[roztom]

SWS: MY OA goes up as my pressure goes up but my NR is zero. I've never had one. Also when I was titrated they ran the pressure up to 16 and I never had a Central.

I argued (discussed) with my Doc that I thought I was having Centrals. I reasoned that what else what cause OA unless they were Central with higher pressure. But my PSG says that is not going on. Counter intuitive even to me.

The fact that my AHI dips at 5 cm and then at 9 cm but is higher everywhere inbetween and above is counterintuitive and I don't register any NR's. MY OA are typically 12 seconds, no matter what pressure they are at.

When I had my PSG I only had 2 OA's the whole night but according to the machine data I have many more. Which is more accurate, I have to go with the PSG.

When my pressure is 9 cm my HI is under 1 at 10 my HI goes to 0.5 but my OA kicks up to 2.0. Is that OA real? HI drops, OA jumps up... Does that make sense, especially since I can show 0 -15 OA in a night but only had 2 during PSG and no Centrals.

This is a puzzle to me. SO I go for the lowest AHI and call it maccaroni.

Thoughts?

Best,

Tom

[guessed]

When I had my PSG I only had 2 OA's the whole night but according to the machine data I have many more. Which is more accurate, I have to go with the PSG.

When my pressure is 9 cm my HI is under 1 at 10 my HI goes to 0.5 but my OA kicks up to 2.0. Is that OA real? HI drops, OA jumps up... Does that make sense, especially since I can show 0 -15 OA in a night but only had 2 during PSG and no Centrals.

The PSG uses dozens of wires, and they calculate the numbers to more decimal places than the data deserves. One would tend to think this is deadly accurate. In one sense it is, they can look at EEG information and other stuff that tells them what is going on. Zoom back a notch, think about your quality of sleep, did that night resemble anything even CLOSE to a regular night's sleep? For most of us, not even. Sometimes the SS results need to be taken with a grain of salt. That wasn't really "YOU" in the PSG any more than a deer in the headlights is really a "DEER" in its natural habitat. These aren't eternal constants they are measuring, these are something to do with your physiology under incredibly unnatural circumstances. Take it for what it's worth. That they report a "titration value" at all, based on two or three hours sampling frame would make a statistician cringe. Worse, they don't even attempt to measure individual variability. It's not even possible to estimate that with only a few hours "sample" of your sleep. And they don't. No need to worship the PSG data. The most important result for most is that you did (or did not) demonstrate that you have sleep apnea, and they take a stab at titrating the pressure. Slightly better than a guess.

As for the different results at different pressures, are you changing the pressure and using the apap in cpap mode? or is the apap changing the pressure in response to certain "events"? If the latter, then you may have the cause-and-effect relationship turned around, the OA events are "causing" the machine to up the pressure. Though the OAs are "associated" with higher pressures, don't BLAME the pressures, blame the soft tissues lining the back of your throat. and THANK the higher pressures for fixing the problem. The fact that you report zero NR's tells me the machine is doing its job perfectly. The fact that the numbers you report are less than 5 tells me you are squarely in the range of "normal" and the differences are probably just background "noise". Certainly nothing alarming going on. Most people can hold their breath for 12 seconds without even blinking, or noticing. I'd say you are a success story. Congratulations.

[-SWS]

Tom, as you might have guessed I see the potential in your data and pressure response for a slight machine-induced CSDB effect, that is probably of little or no consequence to you. However, I will discuss your details in the current APNEA -v- HYPOPNEA thread, since that thread has turned into a theoretical CSDB discussion.

viewtopic.php?t=10545&start=105

[Snoredog]

Gone in the wrong direction? Go back.

Note: If you set your Min. pressure to 9cm, the machine will NOT record anything below that 9cm value, so you are basically now blind with what's actually happening. Move your Min. pressure back down to 6cm so you can see what is happening.

Set your Min Pressure to 6cm.
Set the Max. pressure to 10cm.
Set CFlex to setting 2 see what happens.

For non-M series Auto, make sure any Ramp timer is set to 00:00, any Ramp Starting pressure to 4cm or set no higher than the Min. pressure.

Changing your range is really not going to do much. Yeah I know I moved you down to 10cm. You need to "limit" any peak pressures until you find a stabilized 90%.

Next, examine the events shown at the bottom of your Daily reports at the bottom of each day. Look in the first column for SDB events that increase as the pressure increases, next, look for a low or dip in that trend if there is one (suspect it will be your 90% found for that day, compare to other days). If you don't have any data and everything is piled up on the Min. pressure for that day, then you need to lower the Min. pressure mentioned above.

If that is the case, lower your Min. pressure do not raise it.

[Snoredog]

[quote="roztom"]SWS: MY OA goes up as my pressure goes up but my NR is zero. I've never had one. Also when I was titrated they ran the pressure up to 16 and I never had a Central.

I argued (discussed) with my Doc that I thought I was having Centrals. I reasoned that what else what cause OA unless they were Central with higher pressure. But my PSG says that is not going on. Counter intuitive even to me.

The fact that my AHI dips at 5 cm and then at 9 cm but is higher everywhere inbetween and above is counterintuitive and I don't register any NR's. MY OA are typically 12 seconds, no matter what pressure they are at.

When I had my PSG I only had 2 OA's the whole night but according to the machine data I have many more. Which is more accurate, I have to go with the PSG.

When my pressure is 9 cm my HI is under 1 at 10 my HI goes to 0.5 but my OA kicks up to 2.0. Is that OA real? HI drops, OA jumps up... Does that make sense, especially since I can show 0 -15 OA in a night but only had 2 during PSG and no Centrals.

This is a puzzle to me. SO I go for the lowest AHI and call it maccaroni.

Thoughts?

Best,

Tom

[roztom]

*****MOVED TO HYPOPNEA VS OSA THREAD******


Well I've run my range from 5-14 and here's what happened, using MyEncore to see AHI vs Pressure. At 5 my AHI was under 2.0 then it went up to 4.5 as pressure increased until pressure got to 9 cm then AHI dropped to 2.0 and then at 10cm it started to climb sharply up to 4 at 11 hits AHI 5.

Here's the rub this happens in APAP mode - of course I'm thinking the machine is responding to events right? Logic says yes.

I then try an experiment locking the APAP in 1 CM ranges. 5-6, 6-7, 7-8, 8-9, etc and give it 5 nights each. What do you think eh results would be?

They are the SAME as when the APAP was set for 5 -14. The AHI/Pressure curve is the same !!! You could almost overlay the 2 graphs.

It demonstrates to me that the events are pressure related not that the pressure is event related.

For me it probably means setting my machine to CPAP 9-10. Last night at 10-11 I spent 90% at 10 with an AHI of .04. AMazing to me. Snore zero.
So where do I set it?

It seems according to the data, so far either CPAP 9 or APAP 9-10 or 9-10.5. This is not what I expected from an APAP but it looks to me that a fixed pressure is more conducive for my therapy.

I never expected it to work this way but the data seems to support it.

Thanks,

Tom

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