Why couldn't the machine prevent this cluster?

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AMK
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Why couldn't the machine prevent this cluster?

Post by AMK » Sun Mar 29, 2015 7:35 am

This is a first for me (now that my maximum pressure has been raised from 10 to 15 for the last few days) to have a cluster like the one around 5:00 and not have the machine to go its pressure limit. I have no idea what to think now. Is this where we have to look at preventing activity like that by raising the minimum? Before this I would get hours o' doom like that because the machine couldn't go high enough. But now it can. And it didn't. Pugsy I know we talked about raising the minimum but that was due to flow limitations...this is the first time I've seen something like this with the new settings.

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Re: Why couldn't the machine prevent this cluster?

Post by AMK » Sun Mar 29, 2015 7:37 am

My other question is, what new minimum pressure would (anyone who responds) recommend? I'll write a note to the sleep nurse today and ask her about this.

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Re: Why couldn't the machine prevent this cluster?

Post by Pugsy » Sun Mar 29, 2015 7:44 am

AMK wrote:Is this where we have to look at preventing activity like that by raising the minimum?
Yep
AMK wrote:My other question is, what new minimum pressure would (anyone who responds) recommend?
This is where I would go slowly and actually probably try 0.5 to 1.0 for a week or so to see what effect was had on the clusters.
When I saw this type of thing I was happy with just breaking up the cluster so it was less ugly. I didn't try to totally eradicate them.
So if this had been my report the only real part that I might have been slightly disappointed in would have been that 05:35 to 05:45
and even then I wouldn't be horribly disappointed. It's maybe 10 minutes out of several hours of otherwise quite decent therapy.

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Re: Why couldn't the machine prevent this cluster?

Post by AMK » Sun Mar 29, 2015 8:25 am

Thanks, Pugsy. This ties in with a question I haven't been able to figure out. My range is 7-10. Once things get going, the pressure never goes below 9.36. But you think raising the minimum to 7.5 would make a difference, even though the machine never went that low? The way I had been thinking was that for a preventative minimum, the minimum needed to be set higher than the lowest pressure (9.36) that allowed the event chain to happen. How would 7.5 help?

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Re: Why couldn't the machine prevent this cluster?

Post by Pugsy » Sun Mar 29, 2015 8:44 am

I don't know that 7.5 would help all that much if any based on what you see here....but I don't know that it wouldn't either.
I just have always been very cautious when increasing minimum pressures...it's just my nature.
There's always the chance that we might not need as much as we initially think we might need and I have always been the type of person who tends to want to use as little pressure as possible. Take my time and evaluate things along the way so that all options have been evaluated.

Plus from my own personal experience (which I draw upon a lot which may or may not be that typical) I have seen reports that look like yours and the minimum doesn't always have to be the average to get the job done.
In my case the line in the sand for the minimum when I was using apap was 9 cm vs 10 cm minimum.
9 cm minimum gave me a couple of little ugly clusters like you are seeing and 10 cm minimum broke up the clusters...but if I was going by the overall average (not the 90/95% number) one would thing I needed 12 to get the job done....but I didn't.
I have also experiment with minimum pressures from 10 to 13 (in 0.5 cm increments for 1 week each) just to see if there was really any marked difference between the 10 cm minimum results and the higher minimums....there really weren't any marked changes at all and about all I saw in terms of changes could simply have been normal nightly variations.

For me there was no benefit from using a higher minimum (which was close to my overall average pressure) over a slightly lower minimum....no change in AHI and no change in how I slept or how I felt. If there had been a big difference in any of those 3 things then I would have reconsidered my chosen preferred settings.
Interestingly the experiment up to 13 minimum also never really changed the times I would sometimes see 18 cm pressure needs.

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Re: Why couldn't the machine prevent this cluster?

Post by AMK » Sun Mar 29, 2015 8:52 am

Is my data typical of someone with REM OSA? Can I assume I had REM sleep twice last night and the events happened during those times? I know w/o an EEG there's no way to know for sure. Or do clusters of events happen randomly?

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Re: Why couldn't the machine prevent this cluster?

Post by Pugsy » Sun Mar 29, 2015 8:59 am

The 2 most common causes of obstructive clusters like you are seeing
REM sleep
Supine sleeping
or a combination of a little of the 2.

That's pretty much it.
And don't automatically assume that the only REM sleep you had was with those 2 cluster like times...you probably had more REM than that.
I have had nights on the APAP where my pressure never really changed at all and have a good 7 or 8 hours of sleep and pretty darn sure I had REM at the usual times.
For some reason sometimes REM needs require more pressure and sometimes they don't. Kind of affirms the benefit for APAP mode in this situation.

I have got some old apap reports somewhere....let me see if I can find them so you can see what I mean.
Here's a good example in this thread for auto ranging being a benefit. This happens to be when I was experimenting with a fixed bilevel pressure machine.
viewtopic.php?f=1&t=88508&st=0&sk=t&sd= ... ster+child

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Re: Why couldn't the machine prevent this cluster?

Post by AMK » Sun Mar 29, 2015 9:12 am

As far as I know, I don't sleep on my back at all. I have always hated sleeping on my back because I tend to shoot awake and I know now that was probably due to more severe apnea. Thanks for the link. I'm glad I know I probably got some less-disturbed REM in. I need to learn more about the sleep cycles and stages.

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Re: Why couldn't the machine prevent this cluster?

Post by Jay Aitchsee » Sun Mar 29, 2015 9:48 am

AMK wrote:This is a first for me (now that my maximum pressure has been raised from 10 to 15 for the last few days) to have a cluster like the one around 5:00 and not have the machine to go its pressure limit.
Maybe the machine acted appropriately. Those apneas starting about 04:45 are separated by some time (minutes). After each one occurs, the machine steps up the pressure, which is what it is supposed to do, step up, not immediately go to the max. Once at the new level, it begins to drift back down until another apnea occurs and then another step up, drift down, and the cycle repeats and continues with ever increasing pressure as the events get closer together until the pressure has increased to the point the apneas stop, about 05:47.
The machine increases pressure in the presence of flow limitations, snores, and after obstructive apneas. It does not act during or preceding a specific obstructive apnea. I doubt raising the minimum would have changed the outcome since the pressure never drifted back down that low during the time 04:45 to 5:45. To me, it seems the only thing that might have prevented these events is a fixed pressure at about 14 (not a recommendation, just an observation).
As far as minimums go, since the pressure never falls below 8.8 for the night, a minimum around 8.6 probably could be used, but again, it probably wouldn't make much difference as once the evening begins the machine never drifts to the minimum again.
Now, I offer this for discussion only, since this apparently was a one night occurrence, I wouldn't be in a hurry to change anything.

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Re: Why couldn't the machine prevent this cluster?

Post by palerider » Sun Mar 29, 2015 9:54 am

AMK wrote:Thanks, Pugsy. This ties in with a question I haven't been able to figure out. My range is 7-10. Once things get going, the pressure never goes below 9.36. But you think raising the minimum to 7.5 would make a difference, even though the machine never went that low? The way I had been thinking was that for a preventative minimum, the minimum needed to be set higher than the lowest pressure (9.36) that allowed the event chain to happen. How would 7.5 help?
I'm generally more gung-ho than pugsy... but she has much more experience than I do with this, so I tend to defer to her advice.

but if it were me, I'd set the base pressure at 9.4 and have a go.

but, pugsy is probably right, sometimes it takes less that you'd expect

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Re: Why couldn't the machine prevent this cluster?

Post by Pugsy » Sun Mar 29, 2015 10:31 am

palerider wrote: I'm generally more gung-ho than pugs
Oh, don't get me wrong...I would most definitely investigate that 9.4 (or thereabouts) minimum and probably would even try 10 cm minimum or maybe a little more.
I just would go up more slowly....
1...it's an easier adjustment not that a 2 cm jump is a horrible jump but for some people it can be a massive jump comfort wise.
2...I would want to have the "what if I could have it lower and it still get the job done" question answered in my mind. But that's me. I like to explore all the possibilities.
So going up slowly covers both bases...ease in adjustment (should it be a factor) and answers the "what if" question that I would have in my mind.
Now if we were seeing a LOT of those ugly OA clusters then I would be more aggressive (maybe) but the report as it is now, assuming the other reports are similar, aren't that horrible right now. It's just a matter of a little tweaking depending on just how much OP wishes to tweak and what she wants to accomplish.
She's doing the right thing though...no matter what she is doing...she is educating herself and thinking rather than blindly changing the pressure without understanding why she might be wanting to change something.

In AMK's situation she prefers to run her (and I guess "our") ideas by her medical care team and that's fine (and I certainly don't have a problem with it).
If she and her medical team want to make a bigger jump in that minimum...hey, I have no problem with it.
As always we (as advisers) tend to draw upon our own personal experience as a starting point and I was just offering my thoughts based on what I went through myself with my own battle with REM events that sometimes are little bastards in how tough they are to prevent and sometimes were total wimps and easily prevented.

Oh...before anyone wants to assume that maybe my REM events on steroids were related to the supine sleeping thing being thrown in. I once did a month long experiment in which I built a "wall" that totally prevented supine sleeping because I for sure wanted to rule out supine sleeping being a factor. The result was I still would see the same sometimes big and sometimes none pressure increases in probable REM sleep during that month long experiment. Side sleeping with the wall didn't stop it and for that reason I don't worry about sleeping position because it didn't seem to make any difference.

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Re: Why couldn't the machine prevent this cluster?

Post by palerider » Sun Mar 29, 2015 1:17 pm

Pugsy wrote:
palerider wrote: I'm generally more gung-ho than pugsy
Oh, don't get me wrong...I would most definitely investigate that 9.4 (or thereabouts) minimum and probably would even try 10 cm minimum or maybe a little more.
I just would go up more slowly....
you forgot to quote the "but, pugsy is probably right, sometimes it takes less that you'd expect " part

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Re: Why couldn't the machine prevent this cluster?

Post by AMK » Wed Apr 01, 2015 8:10 pm

I finally heard back from the sleep nurse. She said:
"The flow patterns that you are seeing are typical of what an auto PAP does. It is supposed to go down and then when it senses flow limitation, it will increase the pressure. I do not want to increase the minimum pressure setting, as you are starting to develop central apneas. This is the problem with too much CPAP pressure. Your numbers look GREAT! Let the machine do it's job and don't try to micromanage it. A few events are normal."

I don't know why she thinks I'm starting to develop centrals. I have centrals at odd times. Some nights none, some nights a few. So now I'm in a position of, if I raise the minimum I do it against her advice. I guess since my eyes are again becoming the biggest problem I'll just let this sit for now.