Help with first prescription adjustment for tomorrow dr. apt

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
napasun
Posts: 10
Joined: Mon Feb 08, 2016 2:40 pm

Help with first prescription adjustment for tomorrow dr. apt

Post by napasun » Mon Feb 08, 2016 2:56 pm

Hi,

I am brand new to CPAP use. I've done some reading and been assisted with a lot of background info. While I want APAP, the sleep lab dr. prescribed CPAP, but the machine will do either. I have both central and obstructive apnea, and probably UARS with, at least, chronic sinusitis. I'm considered 'mild' and required a secondary dx to have it covered. I have at least three secondary dxes. I am thin (5'6", 119, BMI 18-19ish) but have lax connective tissues throughout my body, so my airway is lax as well.

The prescription was for constant at 5. I tried it for two nights, with plans to switch to APAP setting at one-month followup. Problem was I didn't get through the first two nights. I had worse apea, having to rip the mask off to get air. Additional events were reflected in the machine's apnea data.

After the first night I had called the respiratory therapist who fitted me and explained how it didn't work. I told her it was my feeling I needed less air on exhale, but the machine wouldn't go from 3 to 4. She said I needed to *increase* the flex so more air would come in for exhale and told me to change it to 2. That was wrong, because that night I tried that and couldn't breathe. It was too much. I think I had been right and needed less. Problem is, there is no lower flex setting than the 3 I started with. It's a Respironics DreamStation. I used humidity and am going to ask for a heated tube for that.

My main question ATM is I have no idea what to ask for as a starting range for APAP, and I'm not sure if my PCP will have the experience. He will write a script based on our conversation or may refer me to an outside sleep specialist. I think 5 is the lowest possible for this machine? Maybe 4? So maybe APAP 4-6?

Here are the details on my at-home and lab with with CPAP studies:

My initial at-home study showed:

18 central apneas and 36 obstructive [central was a surprise!]
12 hypopnea
AHI was 8.1
Oxygen saturation nadir was 92%

My followup, overnight in-lab study with treatment was probably irrelevant other than they decided what pressure I should use. I only slept 2 hours and 16 minutes after the stupid nurse practically read me a riot act to get 6 hours sleep in. I couldn't relax after that! It was a terribly atypical night. She needs to find another occupation.

Sleep efficiency 'was really poor' at 25%
Sleep histogram: 10.7% N1 sleep, 64% N2 sleep, 23.5% N3 sleep, 1.8% REM sleep
EEG: No frank seizure activity. Arousal index was 43.2, almost entirely spontaneous arousals
EKG: Sinus rhythm was seen. Heart rate varied from 58-74 BPM with an average HR of 64 BPM
EMG: no periodic limb movements

Respiratory events:
Average oxygen saturation 93%
CPAP initiated at 4 cm water pressure and titrated up to 5 cm
At final pressure REM was seen for only 1% although the patient did sleep for 105 minutes
AHI was reduced to .57

Thanks in advance for any help on what APAP setting to try?!
Respironics DreamStation, ResMed nose pillow for her

User avatar
BlackSpinner
Posts: 9745
Joined: Sat Apr 25, 2009 5:44 pm
Location: Edmonton Alberta
Contact:

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by BlackSpinner » Mon Feb 08, 2016 3:07 pm

Changing the amount of pressure is easy.
Look for the clinical manual online.

Most people find it really difficult to breathe at level 5, they feel like they are choking.

HOWEVER with a lot of CA's you should not be on a plain cpap machine at a fixed level.

To get used to the pressures try wearing it while watching tv.

_________________
Machine: PR System One REMStar 60 Series Auto CPAP Machine
Mask: Hybrid Full Face CPAP Mask with Nasal Pillows and Headgear
Additional Comments: Quatro mask for colds & flus S8 elite for back up
71. The lame can ride on horseback, the one-handed drive cattle. The deaf, fight and be useful. To be blind is better than to be burnt on the pyre. No one gets good from a corpse. The Havamal

Cardsfan
Posts: 1509
Joined: Wed Apr 29, 2015 3:02 pm
Location: Close to St. Louis, MO

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by Cardsfan » Mon Feb 08, 2016 3:27 pm

Were you diagnosed with central apnea? Everyone has some central apnea events, but that does not mean they have a diagnosis of central apnea. It is based on your central apnea index. (how many events you have per hour). Just because your sleep report shows 18 central apnea events during the test, does not mean you have central apnea.

Also, if your sleep titration at a pressure of 5 reduced your events to .57 that is good. You may not need to set the machine to apap. My original pressure was set to 5 and it worked well.
I eventually moved it up to a pressure of 7 just because of the comfort of more air flow. At 5 I felt I was starving for air.

Does your sleep report give a breakdown of what the AHI of 8.1 is made up of?
The pressure range on your machine is 4-20. It does not go lower than 4, no matter what your exhale pressure relief is set at.

_________________
Machine: ResMed AirSense™ 10 AutoSet™ CPAP Machine with HumidAir™ Heated Humidifier
Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear
Additional Comments:  CPAP 10 cmH20., User since 1/1/15.
Last edited by Cardsfan on Mon Feb 08, 2016 3:45 pm, edited 1 time in total.

User avatar
OkyDoky
Posts: 2870
Joined: Mon Aug 25, 2014 5:18 pm

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by OkyDoky » Mon Feb 08, 2016 3:43 pm

First I want to be sure which model of Dreamstation you have. With Flex 3 is the highest setting and doesn't engage unless the pressure is at least 6.
Here is an explanation by Pugsy on Flex settings.
When you start at 5 cm Flex doesn't even engage at all...so it's irrelevant what you have it set to.
For Flex to engage or be turned on the pressure has to be at least 6 cm.

Flex...it's as much about timing of the reduction during inhale/exhale as it is the actual reduction.
The most reduction you can get is 2 cm at the setting of 3...I know it makes no sense but that's the way it is.
And the amount of reduction is flow based which means it's based on the force of your own breathing.
If you tend to be a rather shallow breather you won't get the full 2 cm reduction at a setting of 3.
Flex relief does not work the same as the EPR exhale relief does on the ResMed machines. It's not a direct per cm reduction per setting like ResMed machines.

What I usually suggest to people is that they try all the Flex settings and even turn it off...and you have to have the minimum pressure be set to at least 6 cm to test things.
Test all settings and choose the setting that seems to fit your own breathing pattern the best and is the most comfortable to you...regardless of the number of the setting.

You can see how to get into the clinical settings here. http://www.apneaboard.com/dreamstation- ... structions
And you can get a copy of your Clinical manual here. Scroll down to section three and follow instructions to get them to email it to you. http://www.apneaboard.com/adjust-cpap-p ... tup-manual

At this time Sleepyhead doesn't work with the Dreamstation but Mark is working to make it work with your machine and I think he is close but not yet. The only software that works with your machine is Encore Pro and is a little more difficult to use. If you are interested in trying it PM me.
As far as APAP settings I would start with a minimum of 6 so you can use whichever flex you choose and maximum of 8 to start with. You really need to monitor the data to see if your AHI is made up of obstructives, hypopneas, or centrals because pressure decreases the first two but centrals are flagged but not treated because there is no obstruction that pressure would help and sometimes increased pressure can increase centrals.
ResMed Aircurve 10 VAUTO EPAP 11 IPAP 15 / P10 pillows mask / Sleepyhead Software / Back up & travel machine Respironics 760

Why is it asking me for a new username when I'm the OP!?

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by Why is it asking me for a new username when I'm the OP!? » Mon Feb 08, 2016 9:08 pm

Wow, this is a lot to take in. I really appreciate all the information! Thanks! Will try to cover the questions:

No central apnea formal dx that I'm aware of. The home study report says: 'Impressions: … The patient did have some central events as well.' Then under recommendations: 'She could return to the lab for a full night of CPAP titration which is recommended given the central events …' I did this. The report from the night at the lab says: 'Assessment: mild positional sleep apnea with an AHI of 8.1 in supine position ', and then says, 'Discussion: … The patient only has mild sleep apnea in supine position and positional therapy alone can treat her because she does not desaturate. [He didn't read my intake notes where I explained why I have to sleep on my back.]

While 5cm worked all night in the sleep lab, it's not working at home. My bed is elevated at home and I wonder if that's affecting things.

I can't figure out which number on the bottom of the machine is the model number and the manual doesn't say, but it looks from the paperwork like it's DSX500, humidifier DOM?

If I change the pressure won't it show on the sim card and they might not like that I changed the prescription when a doctor reviews the sim card data? I know people are doing this themselves but I can't figure out how it doesn't come back to bite them in the medical system.

I have all the printouts from both studies, but I don't know how to sort out what the 8.1 is made of.

I don't see a way to turn off the Flex. It must be in the clinician's settings. I'll check.

Thanks again!

User avatar
Julie
Posts: 19898
Joined: Tue Feb 28, 2006 12:58 pm

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by Julie » Mon Feb 08, 2016 9:25 pm

Please give the brand name of your machine, any names, etc. on the front/top of it, and (after emptying any water out) look for wording, Ref. #'s, etc. on the bottom (of the blower, not humidifier).

Cardsfan
Posts: 1509
Joined: Wed Apr 29, 2015 3:02 pm
Location: Close to St. Louis, MO

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by Cardsfan » Mon Feb 08, 2016 9:40 pm

Julie- it's a Phillips Respironics Dreamstation. And the ref # she gave matches the Auto CPAP
An elevated head of the bed should help your airway stay open.
Your pressure changes will show up in you data. It is not "Illegal" to change your settings.

_________________
Machine: ResMed AirSense™ 10 AutoSet™ CPAP Machine with HumidAir™ Heated Humidifier
Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear
Additional Comments:  CPAP 10 cmH20., User since 1/1/15.
Last edited by Cardsfan on Mon Feb 08, 2016 9:49 pm, edited 1 time in total.

User avatar
OkyDoky
Posts: 2870
Joined: Mon Aug 25, 2014 5:18 pm

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by OkyDoky » Mon Feb 08, 2016 9:44 pm

Why is it asking me for a new username when I'm the OP!? wrote: While 5cm worked all night in the sleep lab, it's not working at home. My bed is elevated at home and I wonder if that's affecting things. If anything elevation would probably help.
I can't figure out which number on the bottom of the machine is the model number and the manual doesn't say, but it looks from the paperwork like it's DSX500, humidifier DOM? The DSX500 is a Dreamstation CPAP Auto full data capable.

If I change the pressure won't it show on the sim card and they might not like that I changed the prescription when a doctor reviews the sim card data? I know people are doing this themselves but I can't figure out how it doesn't come back to bite them in the medical system. Yes it will be recorded on the SD card and they will know. If you educate your self to know why you want to change things some doctors will work as partners in your treatment. Some want total control and they will say don't do it. You have to decide.

I don't see a way to turn off the Flex. It must be in the clinician's settings. I'll check. It's in the My Setup menu if the provider has enabled it for you, you should see it there. Remember when you turn it off there is no decrease in pressure on exhale. If it is not enabled in the My Setup menu, access the clinical settings and look at the comfort settings.
ResMed Aircurve 10 VAUTO EPAP 11 IPAP 15 / P10 pillows mask / Sleepyhead Software / Back up & travel machine Respironics 760

User avatar
palerider
Posts: 32300
Joined: Wed Dec 16, 2009 5:43 pm
Location: Dallas(ish).

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by palerider » Mon Feb 08, 2016 10:25 pm

Why is it asking me for a new username when I'm the OP!? wrote:asks
because you didn't Log in.

_________________
Mask: Bleep DreamPort CPAP Mask Solution
Additional Comments: S9 VPAP Auto
Get OSCAR

Accounts to put on the foe list: dataq1, clownbell, gearchange, lynninnj, mper!?, DreamDiver, Geer1, almostadoctor, sleepgeek, ajack, stom, mogy, D.H., They often post misleading, timewasting stuff.

napasun
Posts: 10
Joined: Mon Feb 08, 2016 2:40 pm

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by napasun » Mon Feb 08, 2016 11:19 pm

Oh haha palerider thanks! I'm surprised I was logged out!

Thanks everyone.
Respironics DreamStation, ResMed nose pillow for her

User avatar
palerider
Posts: 32300
Joined: Wed Dec 16, 2009 5:43 pm
Location: Dallas(ish).

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by palerider » Mon Feb 08, 2016 11:35 pm

napasun wrote:Oh haha palerider thanks! I'm surprised I was logged out!

Thanks everyone.
you have to log in most times you revisit, unless you tick the 'keep me logged in' box, which sets a cookie... then you'll stay logged in until something clears that cookie.

cookies, om nom nom.

_________________
Mask: Bleep DreamPort CPAP Mask Solution
Additional Comments: S9 VPAP Auto
Get OSCAR

Accounts to put on the foe list: dataq1, clownbell, gearchange, lynninnj, mper!?, DreamDiver, Geer1, almostadoctor, sleepgeek, ajack, stom, mogy, D.H., They often post misleading, timewasting stuff.

Janknitz
Posts: 8410
Joined: Sat Mar 20, 2010 1:05 pm
Location: Northern California

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by Janknitz » Tue Feb 09, 2016 8:27 am

Sleeping with your head elevated might cause your head to tip forward and occlude the airway more than lying flat on your back. That's one reason that in lab titrations can't always anticipate sleeping conditions at home. You may need more pressure because of your sleeping position. It's worth a try.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

User avatar
BlackSpinner
Posts: 9745
Joined: Sat Apr 25, 2009 5:44 pm
Location: Edmonton Alberta
Contact:

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by BlackSpinner » Tue Feb 09, 2016 10:29 am

My initial at-home study showed:

18 central apneas and 36 obstructive [central was a surprise!]
12 hypopnea
AHI was 8.1
Oxygen saturation nadir was 92%
This is why we question the locked cpap. There were half as much central apneas as there were obstructives.

_________________
Machine: PR System One REMStar 60 Series Auto CPAP Machine
Mask: Hybrid Full Face CPAP Mask with Nasal Pillows and Headgear
Additional Comments: Quatro mask for colds & flus S8 elite for back up
71. The lame can ride on horseback, the one-handed drive cattle. The deaf, fight and be useful. To be blind is better than to be burnt on the pyre. No one gets good from a corpse. The Havamal

napasun
Posts: 10
Joined: Mon Feb 08, 2016 2:40 pm

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by napasun » Wed Feb 10, 2016 12:40 pm

So the doctor's nurse said my insurance will require another titration to change the initial prescription?! Good grief! Seriously? I need to call the sleep lab doc and see if he can get around this. I was trying to avoid that because I didn't like their service at all. I know I can self adjust the machine, but I think at this early stage I better play the game and not lose the coverage for the machine. I have to have a formal chip reading by a doctor in 1-3 months. I'll tell the lab doc at him I'm elevated. I will also bring up the auto-adjust setting for the central. Maybe that will be sufficient to get a formal setting change without a whole new overnight titration.
Respironics DreamStation, ResMed nose pillow for her

User avatar
BlackSpinner
Posts: 9745
Joined: Sat Apr 25, 2009 5:44 pm
Location: Edmonton Alberta
Contact:

Re: Help with first prescription adjustment for tomorrow dr. apt

Post by BlackSpinner » Wed Feb 10, 2016 1:15 pm

napasun wrote:So the doctor's nurse said my insurance will require another titration to change the initial prescription?! Good grief! Seriously? I need to call the sleep lab doc and see if he can get around this. I was trying to avoid that because I didn't like their service at all. I know I can self adjust the machine, but I think at this early stage I better play the game and not lose the coverage for the machine. I have to have a formal chip reading by a doctor in 1-3 months. I'll tell the lab doc at him I'm elevated. I will also bring up the auto-adjust setting for the central. Maybe that will be sufficient to get a formal setting change without a whole new overnight titration.

First call your insurance. They don't give a damn about your settings.

_________________
Machine: PR System One REMStar 60 Series Auto CPAP Machine
Mask: Hybrid Full Face CPAP Mask with Nasal Pillows and Headgear
Additional Comments: Quatro mask for colds & flus S8 elite for back up
71. The lame can ride on horseback, the one-handed drive cattle. The deaf, fight and be useful. To be blind is better than to be burnt on the pyre. No one gets good from a corpse. The Havamal