Apap pressure setting plan

Julie wrote:Not at all. I think for the moment just pretend the high setting doesn't exist and that it's all about the low one. The thing is that you'll likely get better therapy (and AHI's if it matters) with a slightly higher low setting, one that can address apneas that occasionally hit high spots overnight, because e.g. 4 (machine's default low) is too low (and probably 6 is too) to get to those high points when they occur... takes too long to reach the high ones. But if you set the high # too low, and events can't express themselves (having been effectively capped) that's when you'll get chipmunk cheeks. So let the low one be a bit higher (very many of us are at e.g. 10) for now, maybe 7 for 1-2 nites, and let the high setting BE high, e.g. 20. It won't cause your problems and may help the low setting do its job.

True or false? I am more likely to tolerate a 4/7 setting over a 8/20 setting.

FALSE. But at this point it almost feels like you're deliberately misunderstanding... sorry if I'm wrong.

Have you tried 6 min and 10 max...if so, what were the results both in the detailed reports and how you slept and how you feel?

From what I saw...there's no urgent need to let the machine go higher than 10 if going higher causes you problems and apparently it does.

Heck..your AHI with the tight 4 to 7 range was acceptable as long as you are sleeping decently and feeling decently.
Those flow limitations are likely driving the pressure up but while the machine wants to kill them ...the killing of those FLs might cause more problems than it fixes. So sometimes we make compromises.

You gotta get the sleep first before any of the other stuff matters. Go back to what you were doing (it was acceptable) and then maybe later revisit the more pressure thing if it is really needed.
Sometimes auto adjusting and letting the machine have full rein isn't conducive to good sleep and if that happens we rein it in.

Julie wrote:FALSE. But at this point it almost feels like you're deliberately misunderstanding... sorry if I'm wrong.

I tried 8/20 pressure during my nap earlier today. I could not sleep because of the issues that arise every time the upper pressure is over 10 which include chipmunk affect, loud air sound, and a sense of being overly preoccupied with breathing. See the SH results below. This was less than 1 hour so the high AHI must be from Sleep Wake Junk? I know if I try the 8/20 pressure setting at nighttime I will not be able to sleep and will continue to get a high AHI score. I can't fathom why you think I should tolerate a higher pressure setting over a lower pressure. My experience tells me, at least in my situation, you are wrong.

Pugsy wrote:Have you tried 6 min and 10 max...if so, what were the results both in the detailed reports and how you slept and how you feel?

From what I saw...there's no urgent need to let the machine go higher than 10 if going higher causes you problems and apparently it does.

Heck..your AHI with the tight 4 to 7 range was acceptable as long as you are sleeping decently and feeling decently.
Those flow limitations are likely driving the pressure up but while the machine wants to kill them ...the killing of those FLs might cause more problems than it fixes. So sometimes we make compromises.

You gotta get the sleep first before any of the other stuff matters. Go back to what you were doing (it was acceptable) and then maybe later revisit the more pressure thing if it is really needed.
Sometimes auto adjusting and letting the machine have full rein isn't conducive to good sleep and if that happens we rein it in.

Thank you. You're post always make perfect sense to me. I will work on those reports and get them to you. I appreciate your input.

Hi SteveBR.

What I didn't understand is that you have a history where you tried allowing the pressure to go higher and you struggled adapting to the higher pressure (The data you posted did not show that history so I thought may be your were mistaken). That is not unusual and with time and changes to your equipment your ability to tolerate pressure may improve. So I now understand why you want to limit the upper pressure.

The lower pressure setting can also be important. If it is set to low, often the maximum pressure reached is higher than it needs to be. When the lower pressure is better set, the events can be better prevented instead of just throwing more water on the fire after the blaze has started.

So I recommend that you keep limiting the maximum pressure to avoid problems (only you can judge where that limit is). Setting the minimum pressure higher MAY stop the machine from needing to go to the higher pressures.

+1

TedVPAP wrote:Hi SteveBR.

What I didn't understand is that you have a history where you tried allowing the pressure to go higher and you struggled adapting to the higher pressure (The data you posted did not show that history so I thought may be your were mistaken). That is not unusual and with time and changes to your equipment your ability to tolerate pressure may improve. So I now understand why you want to limit the upper pressure.

The lower pressure setting can also be important. If it is set to low, often the maximum pressure reached is higher than it needs to be. When the lower pressure is better set, the events can be better prevented instead of just throwing more water on the fire after the blaze has started.

So I recommend that you keep limiting the maximum pressure to avoid problems (only you can judge where that limit is). Setting the minimum pressure higher MAY stop the machine from needing to go to the higher pressures.

Yes, when I tried the 8 min - 16 max setting a few weeks ago I had a miserable night so I decided to start completely over with a very low pressure and then gradual work my way up. Thanks to you and others on here I have a better understanding of why it could be bad to go with a too low minimum pressure. (Don't let the blaze start. Great analogy!) So I think I will try 6 min and 10 max as Pugsy suggest and see what the charts will show and also see if I can tolerate. It's just going to take a while before I figure out the best setting for me.

Pugsy wrote:Have you tried 6 min and 10 max...if so, what were the results both in the detailed reports and how you slept and how you feel?

From what I saw...there's no urgent need to let the machine go higher than 10 if going higher causes you problems and apparently it does.

Heck..your AHI with the tight 4 to 7 range was acceptable as long as you are sleeping decently and feeling decently.
Those flow limitations are likely driving the pressure up but while the machine wants to kill them ...the killing of those FLs might cause more problems than it fixes. So sometimes we make compromises.

You gotta get the sleep first before any of the other stuff matters. Go back to what you were doing (it was acceptable) and then maybe later revisit the more pressure thing if it is really needed.
Sometimes auto adjusting and letting the machine have full rein isn't conducive to good sleep and if that happens we rein it in.

Hi Pugsy, I'm not an expert but it sounds like you were spot on with your comments. I did try 6 min and 10 max but could not tolerate that. I then tried a 7 to 9 range thinking it would be a good compromise. I did tolerate that range better but still didn't have the best nights sleep. You can see the SH data indicates lots of SWJ for my nap and when trying to go to sleep. I believe you are correct regarding the flow limitations driving the pressure up and causing more problems than fixing them. I then tried a 6 to 8 range. As you can see from the SH data below there is no SWJ for my nap or as I was trying to go to sleep. The SH data below is for Thursday and Saturday. I forgot to put the SD card in Friday night but my total AHI score was 1.7 and the range was 6 to 8. Do you think I should stick to the 6 to 8 range for a while or try something else? I also want to point out that my AHI scores for range 6 to 8 is on par with range 4 to 7 data. Although I only have a few nights worth of data using the 6 to 8 range where as I have more than a week of data with the 4 to 7 range.

Thursday 7 to 9 range




Saturday 6 to 8 range

There really isn't much else to try given the limited range of pressures that you seem to be able to tolerate.

Should you try something else? I don't know what that would be at this point.
I guess that depends on how you feel..how you are sleeping and whether or not you feel that you need to "improve" anything.

You can always revisit it a bit later. Maybe discuss with your doctor the issues you had with the more pressure and whether or not those flow limitations are a worry enough that they just have to be killed.

Pugsy wrote:There really isn't much else to try given the limited range of pressures that you seem to be able to tolerate.

Should you try something else? I don't know what that would be at this point.
I guess that depends on how you feel..how you are sleeping and whether or not you feel that you need to "improve" anything.

You can always revisit it a bit later. Maybe discuss with your doctor the issues you had with the more pressure and whether or not those flow limitations are a worry enough that they just have to be killed.

Aside from flow limitation concerns would you categorize my overall AHI score as very good? Is a 1.7 and a 1.5 AHI better than most Cpap users? Should I be happy and content with these scores?

Unfortunately, I'm not impressed with my primary doctor's overall sleep apnea knowledge. Maybe I should get a referral to see a sleep specialist. I do feel better overall with the lower pressure settings than I did before therapy.

Correct me if I am wrong. If there's any concerns to have it would be with FL and that may or may not be an issue? My AHI score should not be a concern?

Your AHI numbers are well within acceptable limits in terms of the obstructive components (the OAs and hyponeas).

The bulk of the AHI appears to be CAs/Centrals and we wouldn't/can't fix those with more pressure with your machine.
You a very likely correct in that most of those CAs are SWJ anyway and if they aren't the real deal we ignore them.

Do you have much nasal congestion? Sometimes the machine mistakes nasal congestion for FLs in the back of the airway. If it is nasal congestion then we would tend to not worry so much about those FL graphs because it could be nasal congestion.

Only you and your doctor can decide if the FLs are a real worry or not. If sleeping decently and feeling decent then they may not be that big of a deal especially since trying to kill them causes problems. Sometimes we have to make compromises and letting the FLs slide isn't a bad compromise. I have seen worse.

You can always revisit more pressure later if you wish.

I do have chronic nasal congestion that occurs only at night. I have had 2 septoplasty surgeries that were of modest help. The only thing that has ever really helped me is Afrin but I only use it in one nostril(the one that opens up the most) due to the rebound affect and the potential negative side effects that occurs with long term usage of Afrin. So normally I go to bed with one partially to completely clogged nostril and the other one clear.

With that history with your nose it is very possible that the FLs shown on the graphs are reductions picked up by the machine. It can't tell where the reduction in air flow is...just that it is reduced.
More pressure doesn't usually help in situations like this. I have seen some really ugly FL graphs from people with bad nasal congestion.

Since there is a very reasonable explanation for the ugly FL graph not related to the airway tissues down in the airway below the nose and behind the mouth and below and you are reporting feeling somewhat better.
I would put the FL graph on the back burner for now. Can't really do much about it anyway at this point. If it's in the nose then cpap can't fix it and only the other stuff we do for nasal congestion will help much.

I understand about limiting Afrin use...been down that rebound road myself and it's not much fun. At some point if you can get your nose reasonably clear for the bulk of the night you might again look at the FL graph and see if it looks any less active.

Your machine is always going to want to kill it with more pressure so you will need to limit the max. So anytime you show your reports to anyone be sure to mention that there's a good chance that the ugly FL graph is because of your nasal congestion issues.

Is the nasal congestion something you have always had a problem with at night or is is new since starting cpap?
If you always have had it in the past and it's not new then I won't give you to the humidity speech but if the congestion seems directly related to when cpap was started then you get the humidity speech.
Some people need more moisture and some people need less and when the nasal mucosa are unhappy they react like they would to an allergy response.
So if that's what might be going on you might play with the humidity setting to see if more or less seems to make any difference or not.
If it's chronic and not related to cpap then do what you have to do to be as comfortable breathing as possible. If it's chronic you undoubtedly have lots of experience dealing with it and know what works and doesn't work.

All in all now that we know a little more about your situation...and your limitations at the higher pressures...and you are fortunate that there no urgent need to go higher to deal with the real OA/hyponea events. I would suggest stick with this tight range for now for sure. It's working well.
You are feeling some better and should feel even better as time goes by.
I have seen reports like yours where nasal congestion is the cause of the ugly graph and pressures of 20 wouldn't even clean them up much at all.
Nasal congestion itself doesn't seem to respond all that well to more pressure because of the mechanism for the why for the congestion. It's not the same as flopping airway tissues that can be help open with pressure.

I would work on the mundane job of just getting myself used to the therapy itself and improving my sleep quality. If you have to cheat and use a tiny bit of Afrin in one nostril to get to sleep....well that's what we have to do. When I went to my doctor about my Afrin rebound I was only doing it at night and teeny tiny bit...and he told me that sometimes we gotta do what we gotta do but to be really careful and not let it escalate to daytime use too.
I finally got off the Afrin but it took a lot of work and I used a lot of Flonase to help me get there. He actually told me that there were worse things than using Afrin only at night...but I told him that I want off it because I knew I would be too tempted to escalate the usage.
I know myself and past history with Afrin and didn't want to risk the full rebound. I have been through it enough times to know I don't want to risk it again if at all possible.

If the chronic nasal congestion is actually worse since starting cpap therapy then you might play with the humidity settings (more and less) to see if it helps or makes things worse.

I have had the nasal congestion for many years. If I don't use Afrin I get completely congested (even after no Afrin for months) every night when I lay down. During the day I am okay. Sometimes I will have a rebound from the Afrin in the early evening for an hour or so. I have always wondered how much my congestion effects my sleep quality. If your nose gets congested during sleep your body knows to convert to mouth breathing.(thankfully!) However, there is a point where your nose is only partially clogged and you continue to breath through it but you are not getting an optimal flow.

I actually think cpap gives me the feeling of clearer nasal passages. I will feel like I am breathing fine through my nose and then take off the pillows and then sense some stuffiness. Whether that is due to cpap opening my nasal passages up or just giving me a false sense of them being open more I don't know but overall cpap seems to have helped with stuffiness.

I may try using a FF mask for my nap tomorrow and maybe tape my nose shut to make sure I am only breathing through my mouth and then see how the FL graph looks? Wouldn't that determine if my FL were due to nasal congestion? I just have to remember not to tape my mouth shut too as I have been doing. haha

My newest ENT actually gave me a green light to use Afrin. I was shocked. He also wants to perform my 3rd Septoplasty(very reluctant to have) and do a medial flap turbinoplasty which at least one study shows a much better long term outcome. I think most of my issue is from swollen turbinates since Afrin works so well for me.