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I would like some suggestions on trying to adjust my REMstar Auto A-flex. I did a little reading around the board and I still don't quite know HOW to lower my AHI to below 5. I know I can try changing the pressure on my machine but I don't know anything about a minimum number, that really confused me, all my machine seems to show me when I start the therapy is 13.0cmH2O. Here is the relevant data:

Large Leak:
7 day avg 45% (this is probably because I ran it for 15 minutes to dry the hose)
30 day avg 38%

AHI:
7 day avg 5.4
30 day avg 6.4


Any suggestions would be a HUGE help.

It's a Respironics PR System One REMstar Auto with A-flex if that helps.

MatthewR wrote:Here is the relevant data:

Hi,

A data download with graphs would be great. If you don't have software yet, then a few numbers from your machine would help. That includes your minimum set pressure, your maximum set pressure, and your 90% pressure. While I couldn't give you specific medical advice, I could suggest some rules of thumb about what I might do if I found myself in your position.

-john-

Here is a good forum post to help you get started. Look on the back of your machine to find out exactly what model of machine you have... If you have questions, come back here and ask the members:

http://www.apneaboard.com/adjust-cpap-p ... tup-manual

This is my info I have any other stuff you need let me know, but please offer me some advise on tuning my cpap settings, I cant really afford the doctor visits.

I don't know your mask.. but the very first thing you need to work on is your leak.
You leak line is pretty bad. Go find your mask literature and look for the pressure graph and see how much the vent rate/intentional leak rate is for your pressure of 13.
Vent rate varies by pressure (goes up with increase in pressure) and with mask so you have to figure out vent rate for your mask at your pressure.

I can tell you right now it is no where near what you are seeing on that top leak line.
Top leak line is total leak...which is mask vent rate plus any excess leak.
You are in or nearly in large leak territory for the bulk of the night. It is bad enough to impact therapy. It is bad enough to allow a few events to slip past the defenses.
You can't really expect to clearly evaluate your AHI until your leak is controlled better.
A few minutes of large leak isn't that big of a deal but you are spending the majority of the time in or near large leak.

As a side note..the clusters of events you see right when you first start therapy or after the break in therapy probably aren't real...most likely awake or semi awake events so they are elevating your AHI a bit.

Edit to add this leak example..my mask at my pressure will have a variable vent rate because I used APAP with variable pressures. My vent rate is around 25 L/min...compare your leak rate to mine...see the difference..you need to be below 50 L/min for the bulk of the night. Large leak territory for the new PR S1 machines seems to be around 75 L/min or maybe 90 L/min at the outside..you spend way too much time up in large leak territory.


Are you waking up often due to leaks? If so...you likely have more awake/semi awake events being flagged (the machine doesn't know if you are awake or not).....
Main thing.....fix the leaks...whatever is causing them.
Which mask are you using? If you are using a nasal interface mask and leaving the mouth uncovered then it may be mouth breathing we are seeing here. Whatever it is...it needs serious work before you start even thinking about changing anything else.

Ditto what Pugsy said, the LEAKS are the issue. Until those are controlled, you are not going to be successful lowering your AHI because you are not getting therapuetic pressures. Are you wearing a nasal mask or nasal pillows with your mouth open???

The machine will not score leaks when you're just running it without wearing the mask, so don't blame it on that.

AH thanks for the quick replies. I should have mentioned that I wake up with a dry mouth and eyes. The mask is called ComfortGel Original Nasal CPAP Mask, but I haven't found anything on the leak range. Should I wear a chinstrap then?

I think a chin strap would be an excellent place to start.

A chin strap MAY help, but often it doesn't do the job if you're a mouth breather. Some people use painter's tape over their lips to keep them closed, others go to a full face mask or a hybrid. And you may be able to learn to keep your mouth closed even while sleeping.

Try the chin strap first, and have a plan B and plan C if needed.

Dry eyes suggest that the mask is leaking elsewhere too, so you may need to play around with the fitting or you may need a totally different mask.

I tried the painters tape, and I have some mixed feelings about it, the leak looks better but my AHI got a lot worse. Anyone have any suggestions for me now, i'm getting a little freaked out. Here is my chart from last night:

From the respionics web page you mask leak rate is 24@10 CM H20 and 32@15 CM H20

http://www.healthcare.philips.com/asset ... 111027.pdf

so your 13 would have about a 28CM H20 intentional leak

-tino

When your leak was so bad it is possible that you had events and the machine just missed them...so might explain the lower AHI when the large leaks were rampant.

How is your overall sleep quality? Are you waking often? Having trouble going to sleep and staying asleep?
Laying there in bed awake with mask and machine on for prolonged periods of time?

The time frame from mask on to about 00:15...did you sleep at all? I know there was at least twice where you turned the machine off. What happened?

Thanks Pugsy!
It was very hard to fall sleep with the tape on, so I was laying there awake for maybe an hour or more. I woke up one time in the night, I think, and went back to sleep pretty easily. I don't remember turning my machine off at all really, I don't know what happened. In the morning I was awake for a while before I took the mask off. I feel like the quality may be better but I feet very anxious today, is that to be expected? Tino your saying that my leak is still high then?

Your leak is MUCH improved...your baseline vent rate for your mask at your pressure is around 28 L/min so you are always going to have that much leak showing on that top line in the graph. Even the 28 isn't an exact number because there is a normal variance of around 5 L/min.

If you look at the beginning of the night where we would assume the leak is minimal...your baseline is around 30 L/min...so you are going to have that much all the time anyway...the times you went higher were much less frequent and not nearly as much as on your other reports.
You stayed under 60L/min for most of the night except that last hour. Something happened.
But for the bulk of your night...the leak was well within acceptable limits.

Since you were likely awake during the first hour or two (or semi awake) I think that those events have to be set aside and we can't trust the data. We can't count awake events when we evaluate therapy.

For right now...it is obvious that taping helped...do you want to continue taping and hope that your mouth learns to stay shut or do you wish to add chin strap to see if it offers enough support (I doubt it will be enough) or do you wish to go to a full face mask? When I first started therapy I simply couldn't stand a full face mask so I opted to tape...chin strap wasn't enough because it kept sliding all over the place but you might find one that would work well enough....the PapCap would have been one that I would have tried next if I couldn't get used to taping.
I got used to taping and was able to quit after about 2 months...my mouth learned to stay shut for the most part.
Up to you what you want to do but you have to keep your mouth shut better for sure. We can take a few large leaks but not like you were having.

So again...until you sleep well and don't lay in bed awake getting awake events flagged...we don't worry about pressures... Gotta get good solid sleep first.
I think if we can eliminate your awake time events that your AHI will be very acceptable at your prescribed pressures.