Further adjustment S9 Needed?

I am thinking about raising my pressure range from 7-12 to 8-13.

My AHIs seem higher than when on my M series at 8-11

I had reset my range from 6-10 to 7 -12.4 more than two weeks ago.... but results appear to be higher AHIs?

Are you using EPR of 2? EPR setting of 2 will reduce the pressure by 2 cm during exhale. Your old M series machine didn't reduce nearly as much with their Flex options for exhale relief.

It is possible that the reduction in pressure during exhale is just enough to allow some apnea events to materialize because the pressure may not quite enough keep the airway fully open.

The minimum pressure is the most critical pressure. It needs to be high enough to be able to get to where it needs to be in a timely manner. Your minimum along with EPR may be a bit too low for the machine to be able to get to where it needs to be quickly enough to deal with the events.

Also remember that the M series machines did not score centrals and also remember that we don't treat centrals (even if they are real) with pressure increases because the airway is already open. Your AHI with the ResMed machine will include Centrals. To compare to M Series AHI you need to back out the Central Index.

I can't see your AHI on this report but I do see some clustering or grouping of obstructive apneas which might be positional (on your back) or maybe REM stage sleep. Whatever the cause they are unwanted.

If you want to use EPR of 2...I would adjust the minimum and maximum by 2 cm to allow for the reduction or turn EPR off if it is comfortable to do so. Then see what your reports look like and watch those centrals. That one grouping of centrals near 7:36...is it possible that you were awake or semi awake during that time frame? It is unusual to have such a cluster and really nothing else but random (and normal) centrals.

Does EPR 1 reduce exhale pressure 1 cm and EPR 3 reduce exhale by 3cm?

If so, should I try EPR1 and check results?

rozenbob wrote:Does EPR 1 reduce exhale pressure 1 cm and EPR 3 reduce exhale by 3cm?

If so, should I try EPR1 and check results?

Yep, you sure could try EPR 1...Each setting in EPR is a per cm reduction in pressure during exhalation.
1= 1 cm
2= 2 cm
3= 3 cm reduction

EPR is strictly a comfort feature but if someone is already at the lower end of a threshold where events might sneak past the defenses then that reduction might allow the events to occur. So sometimes a little adjustment is needed depending on patient comfort. I find it easier to breathe with a minimum of 12 cm and EPR of 3 than I do at straight 9 cm...It is the difference that allows for the perception of easier breathing. Maximum...I am asleep so I could care less what it is.
Play with it and see what feels best to you.

Pugsy wrote: . . . and also remember that we don't treat centrals (even if they are real) with pressure increases because the airway is already open. . . .

By what method are the central apneas treated? I'm asking about real central apnea events. In my own situation thus far, on a couple of nights when mask leaks were dramatically reduced (almost totally eliminated, actually for 0.0 leak levels), virtually all the 'centrals' also went away, implying that they were bogus indications to begin with (again, in my case). I'm sure eliminating leaks won't eliminate true central apnea events for me or anyone else.

Papit wrote:By what method are the central apneas treated? I'm asking about real central apnea events. In my own situation thus far, on a couple of nights when mask leaks were dramatically reduced (almost totally eliminated, actually for 0.0 leak levels), virtually all the 'centrals' also went away, implying that they were bogus indications to begin with (again, in my case). I'm sure eliminating leaks won't eliminate true central apnea events for me or anyone else.

It depends on how many centrals and their impact on the body and if there is a known cause for the centrals. It depends on the diagnosis...all centrals or a combination of centrals with obstructive apneas.
A few random and occasional centrals are normal. Whether they are the real deal or sleep onset or turn over in bed cessations of breathing with the airway open.
We don't do anything about those centrals even if they are real except shrug our shoulders and move on.
Some people with more centrals, then we want to see, will have their centrals managed very well with a simple BiLevel machine like the one I use (not for centrals though). Then for more stubborn and problematic centrals a person might need a BiLevel machine that will actually force the person to breathe when they don't breathe like they should because of the number of centrals. What we commonly refer to as ASV machines with various capabilities depending on individual needs.

For people who have plain jane obstructive sleep apnea who only have random normally occurring centrals...we don't do anything. The airway is already open. Increasing the pressure won't help and in some situations can make things worse. If my AHI is 4 and 50% of that is central (or clear airway) index...that means my obstructive component is only 2...and quite acceptable. I ignore the other because I can't do anything about it anyway.

First readings after upping pressures to 8-13

it seems that the majority of events occur above 10...with this in mind, should I REDUCE my top pressure from 13??

rozenbob wrote:it seems that the majority of events occur above 10...with this in mind, should I REDUCE my top pressure from 13??

Do you see where your pressure line hits 13? See where the events are happening near that 13 cm line?
If you reduce the maximum pressure...you will likely see more events show up because the machine can't get to where it needs to go if you limit the maximum even more.

If your events happen above 10cm...then your minimum needs to be closer to where it needs to be to prevent the events.

If you reduce the max and leave the minimum alone you will very likely see an increase in events.

Should I try 14 cm on top or higher?

It seems strange that there were no events at the lowere pressure!

You barely nudged 13cm...if you use 14 cm max..it might go a bit higher and it might not. It still won't prevent the events from occurring.

I repeat....the minimum pressure is the most critical especially if you are using EPR. Those little groupings of events look very suspiciously like events happening in REM sleep.. they are needing more pressure because the minimum pressure cannot get to where it needs to be to try to prevent them from forming.
If you increased the maximum to 20 and left the minimum without any change...your results will still be like last night.

The machine needs a bit more of a head start to get to where it needs to go in a timely manner..the minimum is the head start.

The machine won't go where it doesn't think it needs to go with the maximum but you have to have a good minimum to start with.

I will try 9-14 tonight..Thank You for your explaination

Pugsy definitely knows a lot more about this than I do but I'll tell you what I did--

Set the EPR on 2. Set the pressure on 4-20.

Slept a few nights and looked at my data.

Pressure was 7-11. My AHIs were 5-7.

Slowly cranked up the bottom pressure up to 9 until my AHI's were 0.

Left the top pressure on 20 where it still is set. Top pressure is usually 11. Occasionally goes to 12 or 13.

I feel great and I'm very active mentally and physically with no naps. Wake up between 6-7am. Read from 9-11pm and go to sleep at 11pm.

Ed

You know ResMed and Respironics have different algorithms so the same settings on each machine doesn't guarantee the same results but I think with EPR being in use that you will find the 9 cm minimum more closely resembles your M Series minimum.

Also from past experience I found that there was a threshold where my minimum pressure would give me a marked change in AHI with only a 0.5 change in minimum. Back when I was first starting APAP therapy I found that with a minimum of 9 cm my AHI was around 6... at 9.5 minimum the AHI was 4 to 5 but I still had some clusters probably in REM sleep where I am documented worse but when I increased the minimum to 10 cm...the clusters broke up and I had AHI of around 2 and I finally saw a bit of improvement in how I felt. The clusters were bad for me even if the overall AHI wasn't so horrible... All with maximum of 20 cm because the machine won't go where it doesn't think it needs to go. I did try some experiments up to 13 cm minimum but the AHI never really changed all that much so I went back to 10 cm minimum.

Using the 20 cm maximum...I sometimes saw the APAP go to 16 or 18 cm but not often and not for a long period of time. Usually at a time that I probably was in REM sleep. My long term average pressure on APAP was slightly below 12 and long term 90% pressure was just slightly under 13 cm. My overall long term AHI on APAP was 1.2 with lots of individual night fluctuations. Some good..some not so good.

It was my doctor's NP who told me to just leave the maximum wide open (pressure changes never bothered my sleep or I would have limited the max) because the machine won't go where it doesn't need to go. She also reaffirmed what I had learned with my minimum pressure needs...that the machine sometimes just needs more of a head start. For the bulk of the night I might have done just fine with a lower minimum...it was just for an occasional REM cluster that I needed more minimum. If I hadn't felt so crappy with the clusters I could have left it lower but I had headaches when I had clusters and I didn't wake up with a headache when I didn't have clusters.