First Night on Devilbiss Intellipap Auto, not comfortable

[shirleyAPAP]

Today is the first night for my mum to have the machine on. She had it on for about 2 hours in bed but cannot go to sleep. She did not feel comfortable to inhale and exhale within the mask and it is a big relief after taking off the mask without the machine. But when she did sleep study with the auto CPAP machine in the clinic, she felt very comfortable.

Is there something wrong with my setting? According to her titration report, her lower pressure limit is 4 and higher pressure is 16. I set the numbers accordingly. I also set the smart flex as 4. The model is auto.

Anything else I need to pay attention to?

[Emilia]

Here is what I think and would do:

First, I am confused when you say her titration report had a pressure range of 4 to 16. That seems odd... usually titration yields a set pressure and ranges are set to numbers slightly below and above that to start. Using a 4-16 range is usually done when titration is unsuccessful. The problem is that such a wide range can be problematic. Couple that with your high Flex setting, and it is a wonder she can breathe at all!

However, you don't say what all the settings are in Flex. You have the choice to set Flex as on all the time or only during the Delay feature. You don't mention Delay so I presume you have that turned off?? If you have it set to Full Time, you have a choice of setting it at 1, 2, or 3. You say you have it at 4 which is not an option. The iRounding and eRounding settings DO have settings of 0-5. Each of these can set separately, and provide change to the waveform profile for inhale (iRounding) and exhale (eRounding). Keep in mind, that a setting of 4 is going to produce big changes in the pressures.

Let me give you a scenario. If your mum was titrated with a pressure of, let's say, 10, a good place to start would be a range of 7-11. You could start her off with Delay set at to start out at 5 and get up to 7 in 15 or 20 minutes. Most of us don't use Delay or only use it for a short time before turning it off. I think I had it on for only 2 or 3 nights. These pressures, suggested here, are just average settings, and once she is using them for a week, the data from the software or Smart Codes can give a better picture of whether it needs tweaking.

For myself, I have my Smart Flex on full time at a setting of 2. My iRounding is at 1 and my eRounding is at 2.

Did I already send you a copy of the clinician's manual? I assume you have it if you set up her machine. If not, PM me and I'll be happy to email it to you if you provide me with your email address.

Please take a moment to go up to the User Control Panel (top left) and then Profile---> Edit Equipment and choose the machine, humidifier, and mask from the pull down menus. Then choose to show them in TEXT, not pictures.

Let me know if you need any further help.... I am happy to help you with the machine, software, or questions you might have. Best of luck! I hope she has a better night once you adjust things.

[Slartybartfast]

Emilia's got you covered. I'd just like to add that this machine has a lot of flexibility built in and the setup is important. If you got the machine from our sponsor, CPAP.com, the machine will have come with the clinical manual.

I agree 4 cm low setting is too low. Your mum likely felt she wasn't getting enough air. The minimum that most people feel comfortable with is about 6 cm. And it's important that if you had the ramp set, that the start pressure should be higher than 4 or your mum will feel like she's being smothered.

Usually a successful titration study report will specify a single value, say, 10 cm. That's the pressure at which all, or virtually all, apneic events were observed to cease. From that level, they may recommend a range of pressure, but 4-16 indicates whoever made it didn't have much confidence in their numbers.

The common advice you'll read on this board is to take the titration pressure recommendation, say 10 cm, and subtract two cm for the low pressure limit, and add 2 cm for the upper pressure limit. So for a 10 cm pressure, you'd set the lower pressure at 8 cm and the upper pressure at 12. Once you have some time at that range, you can experiment with changing the pressure limits and see how she sleeps.

For my own case, I didn't like the rapid onset of pressure and rapid diminishment of pressure at the end of each breath expiration an the end of each inspiration, so I set the i (inspiration onset) rounding to the maximum at 5, and the e (expiration onset) rounding also to 5, which mimics the feel of my S9 Autoset.

It might be worth a talk with the sleep lab about why they set such a wide range. Seeing that wide range is sort of like shooting in the dark, hoping to hit your target.

[shirleyAPAP]

Emilia - I just PMed you my email address. Can you please send me the clinical manual? I need to better understand all the settings. The manual I have is only a general instruction and does not talk about the setting function in detail.

The following is my mum's tiration report:

Mode: APAP
SofPAP: 2:normal
Lower pressure limit (hPa): 4.0
Upper pressure limit (hPa): 16.0
pressure rise (hPa/s): 0.2
average therapy pressure (hPa): 9.4 min: 4.0 max: 15.8
"RDI" (/h, without snoring events): 10.5
number of obstructive events (/h, apnea +hypopnea): either 57 or 5.7 (cannot see it clearly)
number of central events (/h, apnea+hypopnea): 4.7
resistance indicating patterns (RIPs) (/h): 11.0
number of snoring episodes (/h): 5.4

Analysis of selected period
Pressure (time-dependent) Pressure (event-dependent)
50% 10.0 9.0
95% 13.0 12.0

Currently the setting of the machines is:

Lower pressure limit: 4
Upper pressure limit: 16
delay time: 20 min
delay pressure: 4.0
tubing length: 1.8m (6ft)
heater: 4

I bought the machine from CPAP.com. The local mask therapist helped with the setings according to the tiration report.
When you say "titration study report will specify a single value", do you mean "average therapy pressure" on the tiration report?

Emilia and Slartybartfast, thanks for your help! In the meantime, I'll also read the clinical manual in detail this weekend when I receive it.

[Slartybartfast]

Well, it looks like Emilia is brushing the hair balls out of her cat's coat, so I'll take a stab at it:

[snip]
The following is my mum's tiration report:

Mode: APAP
SofPAP: 2:normal
Lower pressure limit (hPa): 4.0
Upper pressure limit (hPa): 16.0
pressure rise (hPa/s): 0.2
average therapy pressure (hPa): 9.4 min: 4.0 max: 15.8
"RDI" (/h, without snoring events): 10.5
number of obstructive events (/h, apnea +hypopnea): either 57 or 5.7 (cannot see it clearly)
number of central events (/h, apnea+hypopnea): 4.7
resistance indicating patterns (RIPs) (/h): 11.0
number of snoring episodes (/h): 5.4

Analysis of selected period
Pressure (time-dependent) Pressure (event-dependent)
50% 10.0 9.0
95% 13.0 12.0

Currently the setting of the machines is:

Lower pressure limit: 4
Upper pressure limit: 16
delay time: 20 min
delay pressure: 4.0
tubing length: 1.8m (6ft)
heater: 4
[snip]

Ok that's very helpful. Note the report says that the average therapy pressure was 9.4, with a minimum of 4.0 and max of 15.8. 4.0 is likely the starting point. 15.8 appears to be the highest pressure reached during the study. It looks like the sleep lab hooked your mum up to an automatic machine and let the machine do the titration. The lab I went to had me hooked up to a machine that the sleep tech manually adjusted remotely through the night in response to my snoring, breathing abnormalities, EEG data, hat size, etc. And the report he generated said that all events ceased at 11 cm. In your case, the machine generated a 95% pressure of 12 or 13 cm which I highlighted in red. That means while the machine was running and adjusting the pressure up and down responding to breathing abnormalities, 95% of the time the pressure was 12 or 13 cm or less. It's sort of the same concept as 2 standard deviations in a statistical treatment of a data set. Same with the 50% pressure being 1 std deviation.

Were I you, I'd choose the lower of the two numbers, 12 cm, then set the minimum pressure at 3 cm below that, or 9 cm, and the upper pressure at 16 and see how your mum does. The report indicates average pressure was 9.4 cm, so 9 cm is a good starting point. 4 cm is way to low. And make sure that if you're using the ramp feature, that you start it at no less than 6 cm pressure. 20 minutes ramp time is what most people start with. In a few days or weeks, the ramp won't be necessary and you can either shorten the ramp time to 5 minutes or turn it off if your mum is OK with starting at 9 cm pressure.

[Emilia]

Based on these numbers, this is what I would do, but this is my opinion, and is not medical advice:

1. Set the Delay to start at 6 for 15 or 20 minutes
2. Set the Low pressure to 9
3. Set the High pressure to 15

Smart Flex = On Full Time, set at 3 (this can be tweaked as necessary)
iRounding = 2 or 3
eRounding = 2 or 3

I'd keep this formula for at least 4 or 5 days and view the data carefully. Once any patterns appear that need addressing, you can change things slightly and then repeat again for 4 or 5 days.

Do you have the software? If so, feel free to share reports with me via email for my opinion. If you are using Smart Codes, you will get good info, but not as detailed as the software can give you. Hopefully, you won't need to adjust things much.

What kind of mask is your mum using? Be sure it is fit properly, and watch the leak info. DeVilbiss doesn't consider anything less than 95 a large leak, but the mask has its own acceptable leak rate which you should be able to find in the manual that came with the mask. If it is, say, 25, you probably don't want leaks too much higher than 35 or so. I sometimes get a spike up to 50, but it is still not a large leak per DeVilbiss. My leak line on the graph in the software is always empty.

Feel free to email me over the weekend, if needed..... glad to help you get your mom situated and comfortable.

[Emilia]

LOL... Slartybartfast and I think alike!! Ah... great minds. The cat's coat is now beautiful....

[shirleyAPAP]

Thanks!!! You guys are awesome.

I'll try tonight.

[shirleyAPAP]

Friday night update: She felt comfortable with the machine at first and went to sleep. But after an hour she woke up and felt a little bit difficult to breathe again just like yesterday. Emilia/Slartybartfast, do you have any suggestions how to adjust my settings?

Currently my setting is:
Delay start at 6 for 20 minutes
Low pressure at 9
High pressure at 16
Smart Flex = On Full Time, at 3
iRounding at 3
eRounding at 3

It's much better than last night. During the time when she had the mask on, she snored far less than usual. (but why is she still snoring a little bit? I suppose she won't snore with APAP machine?) Usually when she woke up during the sleep, she felt thirsty and want to drink. But not this time. So that's a good move.

BTW, I have not bought the software. It seems that smart code which is bulit in to the machine also provides some kind of summary data. Is it enough to help track of the sleep status? Are those data shown on the display screen of the machine?

[Emilia]

Hi Shirley,
First, what kind of mask is she using? If she is snoring, it sounds like a nasal mask or pillows. If the mouth is opening to allow for snoring, either do taping or try a full face mask that covers the mouth and nose. Many folks here tape their mouths so they can still have the open feel from using nasal pillows. If one snores, the therapy is literally going out the mouth. Our mouths tend to fall open during REM sleep as well, due to muscles being lax.

What do you mean "....she won't snore with APAP machine?" ?? You are using an apap machine...that is what the Intellipap Auto Adjust is!!

I'll ask you again to please go up to the User Control Panel and fill in your equipment so we don't have to continue asking about these items.... Go o User Control Panel and then Profile and then Edit Equipment -- on that page select you mum's gear from the pull down menus and then choose to show them in TEXT not pictures. This puts the equipment at the bottom of each post you write automatically, like mine below.

Smart Codes will give you the basic info numbers, but it will not provide you with the graphs to see when events are happening. The graphs provide a window into the entire night to know when pressure spikes, when leaks occur, etc. Smart Codes will just give you stats without knowing when these are happening. I'd strongly encourage you to get the software when you can afford to do so. It is readily available from our host, cpap.com.

Do not adjust settings again....let this set up stand for a few nights to allow for adjustment and results. Changing things daily is NOT therapeutic.

Did you, at least, plug last night's Smart Codes into the web tool to get results? If you can give those to us, it will help..... You can use the tool on cpap.com for this here -- plug the code into the box at the top of the page and get the results: https://www.cpap.com/cpap-machine/devil ... tflex.html

[shirleyAPAP]

Profile updated. You do not need to ask again.
She is using full face mask. Is it normal for people to snore when using CPAP/APAP machine? (even though she snores far less than usual)
The smart code for Friday night is FD8F-9QV-KQQ2.

[Emilia]

Here are the Smart Code results....







I am confused by the short amount of time indicated here.... only .6 of an hour?

Secondly, the AHI of 24.5 is very high and indicates something is amiss.

It is hard to know if you should try to adjust things with so little to go on. If there was only a half hour to base these stats on, it would be foolish. If she can sleep for at least 2-4 hours to get a better idea of how it is going, it would be easier. Having said that, and seeing how the 95%tile pressure was 15.5....meaning she was at or below that pressure for the amount of time she slept, it might mean a different setting is in order. However, I am reluctant to suggest that due to such a short time span of data.

There were quite a few NRI and EP's as well.... but, again, in only a half hour of data, I don't know what to make of it. This is where the software would be so much more helpful as we could see what is happening.

I will ping Slartybartfast and ask for a second opinion....

[shirleyAPAP]

Yeah. I'm worried about those numbers. They are pretty high. I'll ask her to wear more hours tonight to get more accurate numbers.

[archangle]

Friday night update: She felt comfortable with the machine at first and went to sleep. But after an hour she woke up and felt a little bit difficult to breathe again just like yesterday.

If possible, look at the pressure reading on the machine when she's having trouble breathing. When she has difficulty breathing, see if you can get her to lift up the edge of the mask and feel the air gushing out. And hold her hand over the exhaust port and feel the air flow. This may help convince her she's getting enough air. Or simply inhale and exhale deeply for a minute or so with the mask on.

Doing CPAP during the day while watching TV, reading, etc. may help her get comfortable with it, too.

[ozij]

Secondly, the AHI of 24.5 is very high and indicates something is amiss.

Not when the length of f therapy is 0.6An AHI based on 0.6 hours of therapy is meaningless - a statistical fluke - I ignore anything based on less than 1.5 hours, after the ramp (delay) is finished.

Looking at the 95% and 90% pressure, and assuming you really have the machine set up for Auto, I suspect the DeVilbiss is doing what it does for some people: zooming uncontrollably to the top of the range - its a very short period, and yet you're almost hitting the top of the range as is.

You have to realize that Automatic Positive Air Pressure machines - i.e. APAP's - i.e. self adjusting machines - respond based on how they are programmed to respond by the company, and different APAPs respond differently. When an APAP fits your breathing pattern, it's wonderful. When it doesn't, you may have to consider a different make.

Can you tell us a bit more about your mother? Why it is you posting, and not your mom? How do you know she's still snoring? Is she involved in her therapy, cognitively capable of understanding why it is necessary?

Can you borrow or rent a different type of machine before the time runs out for exchanging the one you have?

If you absolutely can't get your mother to use the machine for longer periods at the present settings, try capping the Max (e.g. at 10) and then raising the Max gradually - at little bit higher every 4 days or so.

I'll repeat: the efficacy (that is, AHI) data you get from sessions that are so short are meaningless.