New SleepyHead Data - Please advise

[jweiner]

So I have been slowly adjusting the minimum pressure on my machine with the hope of lowering my residual AHI as much as possible. I first went from 4 to 7 and last night I went from 7 to 8. My residual AHI was 4.2 this morning. Any thoughts on further adjustments? Thanks in advance!!

[LSAT]

So I have been slowly adjusting the minimum pressure on my machine with the hope of lowering my residual AHI as much as possible. I first went from 4 to 7 and last night I went from 7 to 8. My residual AHI was 4.2 this morning. Any thoughts on further adjustments? Thanks in advance!!

I think if you would slowly increase your min pressure to 10, your AHI would drop.

[jweiner]

I don't feel all that bad. However, I upgraded to this machine from the ResMed S9 and that machine always got my AHI down to <2. I am just curious why this machine hasn't been able to do that. I know that the algorithms are not the same, but (I thought) the goal of any APAP machine is to reduce the AHI as much as possible.

[Pugsy]

know that the algorithms are not the same, but (I thought) the goal of any APAP machine is to reduce the AHI as much as possible.

Same goal but the road they travel to get to that goal is different (the different algorithms).
And to top it off the hyponea criteria for ResMed is different from Respironics.

What were your settings on the S9?

[palerider]

I don't feel all that bad. However, I upgraded to this machine from the ResMed S9 and that machine always got my AHI down to <2.

"changed" not "upgraded".

your new machine is much slower and less responsive, raise the minimum pressure.

[jweiner]

know that the algorithms are not the same, but (I thought) the goal of any APAP machine is to reduce the AHI as much as possible.

Same goal but the road they travel to get to that goal is different (the different algorithms).
And to top it off the hyponea criteria for ResMed is different from Respironics.

What were your settings on the S9?

My settings on the S9 were 4 and 20. I never had to change from the original settings. Do you think I should raise the minimum pressure anymore?

[Pugsy]

I don't want you doing anything without understanding what you are doing and why.
Which means that you have to understand the different components of that AHI and how each responds or doesn't respond to "more press".

I don't want you chasing numbers without also evaluating how you feel and how you sleep. The best numbers on paper don't guarantee that you will sleep and feel great. I wish it was that easy but it isn't.

I have tried to explain the why behind what we do or don't do so that you can learn what you are doing and why.. I want you to think about what and why.

So...you evaluate the components of the AHI individually.
ClearAiray Index..centrals...we don't fix them with pressure from your machine...can't. And you aren't having enough of them to warrant the use of the machine that can...and we don't know even if they are real or if they are sleep/wake/junk centrals and if the are SWJ they don't count and you have to ignore them.

Obstructive Apnea index and the Hyponea Index...these you can try to fix with more pressure. The question is "do you need to fix them with more pressure so that the number of those obstructive in nature events will reduce?"
That's where the objective feelings of how do you sleep and how do you feel come into play...if the obstructive stuff is averaging 2 to 3 per hour...do they need reducing? Maybe yes...maybe no.

Now I also look at the obstructive stuff that isn't part of the AHI...snores and Flow limitations....am I seeing a little more of those than I want to see even if the AHI is quite low.. In your case they aren't horribly horrible but there's still a little more than I would want to see if it were my report regardless of the AHI.

Are you going to have to use more minimum pressure with the Respironics machine than with the ResMed....yep...and that doesn't surprise me.
The algorithms are different. Respironics goes up slower and comes back down slower than ResMed algorithm. Is one better than the other because it goes up faster...maybe if you need the speedy response but for some people they might not need that speedy response.
Is one better because you can use lower pressures in the minimum...maybe if that works out better for you.
It will for some people but not for others and others couldn't tell you any difference between the 2 machines.

So....Your obstructive components of your AHI are roughly half of your AHI...and they are in the neighborhood of it technically being within acceptable limits....if you are sleeping good and feeling good. If not...try to kill more of them with more pressure but always remember that you have to remove the central component of your AHI when evaluating things and don't go by numbers alone...always include how your feel and sleep because that's the end goal...not a perfect math score.

Remember...the best math scores in the world don't mean squat if you feel like crap.

[jweiner]

I don't want you doing anything without understanding what you are doing and why.
Which means that you have to understand the different components of that AHI and how each responds or doesn't respond to "more press".

I don't want you chasing numbers without also evaluating how you feel and how you sleep. The best numbers on paper don't guarantee that you will sleep and feel great. I wish it was that easy but it isn't.

I have tried to explain the why behind what we do or don't do so that you can learn what you are doing and why.. I want you to think about what and why.

So...you evaluate the components of the AHI individually.
ClearAiray Index..centrals...we don't fix them with pressure from your machine...can't. And you aren't having enough of them to warrant the use of the machine that can...and we don't know even if they are real or if they are sleep/wake/junk centrals and if the are SWJ they don't count and you have to ignore them.

Obstructive Apnea index and the Hyponea Index...these you can try to fix with more pressure. The question is "do you need to fix them with more pressure so that the number of those obstructive in nature events will reduce?"
That's where the objective feelings of how do you sleep and how do you feel come into play...if the obstructive stuff is averaging 2 to 3 per hour...do they need reducing? Maybe yes...maybe no.

Now I also look at the obstructive stuff that isn't part of the AHI...snores and Flow limitations....am I seeing a little more of those than I want to see even if the AHI is quite low.. In your case they aren't horribly horrible but there's still a little more than I would want to see if it were my report regardless of the AHI.

Are you going to have to use more minimum pressure with the Respironics machine than with the ResMed....yep...and that doesn't surprise me.
The algorithms are different. Respironics goes up slower and comes back down slower than ResMed algorithm. Is one better than the other because it goes up faster...maybe if you need the speedy response but for some people they might not need that speedy response.
Is one better because you can use lower pressures in the minimum...maybe if that works out better for you.
It will for some people but not for others and others couldn't tell you any difference between the 2 machines.

So....Your obstructive components of your AHI are roughly half of your AHI...and they are in the neighborhood of it technically being within acceptable limits....if you are sleeping good and feeling good. If not...try to kill more of them with more pressure but always remember that you have to remove the central component of your AHI when evaluating things and don't go by numbers alone...always include how your feel and sleep because that's the end goal...not a perfect math score.

Remember...the best math scores in the world don't mean squat if you feel like crap.

Thank you Pugsy!! I totally get it. I am also somewhat of an anomaly when it comes to my sleep apnea. My ESS score is 1-2. I never had symptoms, but my wife noticed that I occasionally had apneic episodes when I was sleeping. I've always been a loud snorer. I had a sleep study and, low and behold, my AHI was about 20. Again, I never really had any objective symptoms of sleep apnea other than my wife noticing apneas when I slept. I totally get the central apneas versus the obstructive apnea thing too. Last night, I set the minimum pressure to 8.5 and my AHI this morning was 4 (the lowest it's been so far on this machine). I just thought I'd share my story with you. By the way, what does EPAP mean in the SH software? it's on the same graph as the pressure. Thanks again!!

[Pugsy]

EPAP is essentially the pressure when talking about reports from cpap/apap machines.

On bilevel machines we have 2 distinct pressures (EPAP & IPAP) available and on cpap/apap machines essential 1 distinct pressure unless using some form of exhale relief and the exhale relief essentially creates a bilevel situation which may or may not seem distinct to a person.
With ResMed EPR exhale relief the bilevel situation it creates is more distinct and easily felt.
Respironics with their Flex exhale relief it isn't quite as distinct in terms of how we feel the drop during exhale. Again the way the 2 brands goes about doing the exhale relief is different. I have actually used both forms (ResMed and Respironics) and while I can tell the difference I can't really say that one is better than the other.

EPAP...exhale positive airway pressure
IPAP....inhale positive airway pressure

You are using Flex exhale relief...so you get a bit of a drop during exhale. That's why there are 2 lines on the pressure graph. Top one is inhale and bottom one is exhale and explains why your pressure minimum setting might be 8 and it shows epap of 7 something.

[jweiner]

Pugsy - based upon my numbers, do you think I should try going to a minimum pressure of 9 just to see what happens with my AHI, or would that be overkill since there are times during the night where it doesn't look like I even need that much pressure? Thanks again!

[Pugsy]

Pugsy - based upon my numbers, do you think I should try going to a minimum pressure of 9 just to see what happens with my AHI, or would that be overkill since there are times during the night where it doesn't look like I even need that much pressure? Thanks again!

I would at least try it to see what happens. Can't hurt anything unless you end up developing bad aerophagia and that's not likely if you aren't seeing it now.

When I was first doing cpap and using the apap mode I started with the minimum of 8 and quickly learned it wasn't enough for what appeared to be REM stage sleep OSA events which wasn't a big surprise since on my sleep study my OSA was 5 times worse in REM than in non REM.
So I settled on 10 minimum and 20 max....the 8 cm minimum worked well for the non REM times but allowed too many events to happen in REM because it just couldn't get to where it needed to be fast enough and it needed to be was running 16 to 18 sometimes more.
So 10 minimum allowed me to break up the REM clusters and it was high enough that the machine get get from 10 to 16 in a timely manner.
My AHI was running 2 to 3 and back then centrals weren't flagged separately...long story with no time to explain...

So I spent some time at 10 minimum and 20 maximum. Then I decided to try more minimum to see if anything changed.
I decided to increase the minimum 0.5 cm weekly to see what happened. I ended up over several weeks going to 13.0 cm minimum. Took about 6 weeks I guess it was with 0.5 cm increase each week. Prepared to abort the experiment if anything bad happened...mainly aerophagia was in the back of my mind because I had the occasion to have it happen to me really bad just a couple of times and didn't know why.

At any rate my AHI never really changed from the 2 to 3 it was running. Sometimes I would get 1.0 to 2.0 but not consistently enough to say it was the higher minimum because I would occasionally see 1.0 to 2.0 even with the 10 cm minimum though maybe not quite as often. There's always going to be some really "good" nights and some really "bad" nights no matter what settings.
So the AHI never really changed even with the 13 minimum and I didn't notice any difference in anything...way I felt during the day or sleep quality itself.
My sleep quality is always fragile but not because of anything related to sleep apnea.

So I learned (and accepted) that more minimum didn't really change anything for me and since it didn't I decided that there was no sense in using more than 10 cm. So I went back to 10 minimum. I learned something though....I learned that more pressure doesn't necessarily fix everything and I learned that it didn't change how I felt or slept.

Since you really haven't noticed any of the usual sleep apnea symptoms you don't really have much to go on besides the numbers but the numbers are just a guide for those that need numbers as some sort of validation. We humans seem to like to have some sort of definite "number" as a way of measuring anything and while that's all well and good sometimes numbers don't mean a whole lot.

If I were in your shoes I would try more minimum if for no reason than to satisfy my curiosity about "is this as good as it can get"...and it doesn't hurt to try unless you end up with aerophagia issues or even less likely pressure triggered centrals (not nearly as common as people think and doesn't have to be a "high" pressure anyway).

Also remember that some of your flagged events could very well be related to Sleep/Wake/Junk and those simply aren't real and don't count in the evaluation process. Over time and with experience you can get a feel for SWJ events and be able to mentally remove them from the evaluation process.
There's a lot to learn in the meantime about what the flow rate looks like when SWJ is involved. May seem like Greek to you now but with time and practice you can get a feel for what asleep breathing looks like and what awake/semi awake breathing looks like.
See this thread if you want to learn more about identifying SWJ.
viewtopic.php?f=1&t=114600&p=1110933#p1110933

This is a marathon and not a sprint...take your time and watch the reports for trends and patterns and realize that there can be some rather substantial variations sometimes. We can all have some really "off" nights sometimes for unknown reasons. I once had 17 centrals in 17 minutes and they sure looked like centrals when I zoomed in on them. Highly unusual for me to have many centrals at all and then to have 1 right after another for 17 minutes...extremely unusual. Never happened again like that. Have no idea why so I blamed it on the aliens....the aliens get blamed for a lot of stuff when we can't think of anything logical. It's as good of an excuse as any.

[ajack]

Going by that chart, I think you are going to finish up around 11 min 14 max. As you move slowly in on your best numbers, it will become more apparent what min pressure is working and how much max you need.
2cm above and below the 95% isn't a bad rule of thumb with a dreamstation.

I would try some aflex, setting 1 or 2 and see how you like it. It lessens the pressure when you breathe out, feels more natural to some. I would ignore any increase in CA, as my best guess is that it will settle in time. You don't have a real problem with them anyway.