need opinions on pressure settings

[Ldempke]

question and settings are at bottom of this post. I can't help but list things chronologically.

BACKGROUND:
overnight sleep study at VA. (Female, 48, 68",202 lbs, 30.8 BMI)
recording time 6.6 hours. slept 5 hours. sleep onset latency 53 minutes, sleep efficiency 77%, arounsal index 14, awakening index 1.
REM latency 3 hours 16 minutes. N1: 3%, N2: 73%, N3: 17%, REM 7%
34 OBA's and 37 hypo for AHI of 14. AHI supine 21. the nadir oxyhemoglobin saturation is 79% from a mean of 95%.
ECG and EEG normal.
PLM: 29 periodic limb movements w/o significant arousal.
IMPRESSION: This recording is consistent with:
1. Mild to moderate sleep disordered breathing (OSA) 2. Loud snoring. 3. Obesity 4. Sleep onset insomnia
PLAN: If the patient is agreeable to long term CPAP therapy, it is recommended she be referred back to the sleep laboratory for a polysomnography with CPAP titration. It is also recommended that in this instance, she will be provided with a medication such as zolpidem to hopefully extend sleep. Alternatively, she could be provided with an auto titrating CPAP instrument set at a pressure between 4 and 9 cm of water. Alternative treatment include: oral appliances, weight loss and upper airway surgery.

PCM referrred me to CPAP clinic where I was issued equipment and instructions. RESMED S9 with H5i and Swift FX nasal pillows. I left with 2 phone numbers: one for problems, and one for new supplies. I used it religiously for 5 to 6 months without observing any improvements in my primary complaint. Fatigue. Began concentrating on other possibilities of fatigue; using CPAP occasionally.

FAST forward 2 years:
still chasing down fatigue, decided to get clean supplies and use CPAP again..and discovered this group!! and Sleepyhead software! During first 2 weeks, sleepyhead showed:
average AHI to be 6.5.
Pressure: PR Max=0, 95%=7.61, med=7.02, PR min= -1.12
Leaks were from removing mask. learned how to go into settings and turn on "smartstart" feature. THANK YOU! also realized I could adjust settings if I chose, but decided to the 'right' thing and call CPAP department. (sent them SD card by mail, 10 days later took equipt in for pressure adjustment.)

NEW SETTINGS: APAP 6.0-11.0
after 5 days of use, here are the new readings:
AHI: 5.95
Pressure: PR max=11, 95%=10.95, med=9.8, min=6

It seems to me the max pressure needs to go up since it is 'bumping the ceiling'.
but I am surprised that the 95%/med numbers are so much higher than they were just a few weeks ago. why would that be?

I am willing to set it myself this time, after considering all your experienced opinions. (all disclaimers accepted).
RESMED S9 with H5i and Swift FX nasal pillows.

Thank you in advance,
Thank you, Thank you, Thank you,[/b]

[Ldempke]

Julie-
Thanks for the thoughts about mouth breathing affecting flow rate. although I tend not to mouth breath much... but that doesn't mean I haven't been with the higher pressure. although my leaks look low on the graphs to me. Here are the graphs:

https://www.dropbox.com/s/2hohxz9xu6ctl ... 0leaks.JPG

so now I am wondering if this graph indicates a decent low leak level? or am I confused and because this is a RESMED 9, it is only graphing excess leakage, and this little purple line in the leak chart is still very bad and needs to be improved?

EDIT: removed poor quality photo that was hosted on photobucket, and inserted link to view image on dropbox.

[Pugsy]

I can't see the graph image....don't know if it is me or your posting.

But how high does the leak go? If it goes over 24 L/min for prolonged amount of time then leaks could be an issue but if you don't hit 24 L/min then the machine can compensate for leaks up to 24 L/min and even if you go past 24 L/min for short periods of time it isn't likely to impact therapy all that much unless the time over 24 L/min is lengthy..so it depends on how far above 24 L/min and how long you stay up there.

Higher pressures don't always blow out the mouth. I see pressures of 20 cm almost every night and no leaks to speak of during those high pressure times.

Regarding pressures and your AHI.
Is that AHI primarily OA and hyponeas? Then yes...maybe a little more minimum pressure and maybe a little more maximum. Probably 1 cm each would do a good job.
If the AHI is primarily Central then we don't treat centrals with more pressure.

[palerider]

I can't see the graph image....don't know if it is me or your posting.

But how high does the leak go? If it goes over 24 L/min for prolonged amount of time then leaks could be an issue but if you don't hit 24 L/min then the machine can compensate for leaks up to 24 L/min and even if you go past 24 L/min for short periods of time it isn't likely to impact therapy all that much unless the time over 24 L/min is lengthy..so it depends on how far above 24 L/min and how long you stay up there.

Higher pressures don't always blow out the mouth. I see pressures of 20 cm almost every night and no leaks to speak of during those high pressure times.

Regarding pressures and your AHI.
Is that AHI primarily OA and hyponeas? Then yes...maybe a little more minimum pressure and maybe a little more maximum. Probably 1 cm each would do a good job.
If the AHI is primarily Central then we don't treat centrals with more pressure.

I can see it, 95: 2.4, max 13.2 leak. pressure med 10.6, 95%: 11, max 11. 3.5 OA 1.07 CA. CA may be swj, all in last 15 minutes.

[Pugsy]

I can see it, 95: 2.4, max 13.2 leak. pressure med 10.6, 95%: 11, max 11. 3.5 OA 1.07 CA. CA may be swj, all in last 15 minutes.

Thanks.
I still can't see it. I get the word "image" and no link, no nothing.
Not the first time this has happened though and that's why I mentioned it might be me.

To OP
Max leak of 13.2 .....well below large leak territory of 24 L/min even at its worst....if you are mouth breathing any it sure isn't very much and I wouldn't worry about it as long as leaks don't wake you up.

In terms of pressure...looks like you are spending a good bit of time up around 10 ish since the median is 10.6.
I suspect the minimum could stand just a little increase and the OAs should reduce a little. Sometimes when the minimum is more optimally set we see the maximum pressure actually drop or at least not spend so much time up bumping the max line. I think I would probably still increase the maximum a little bit also. See where it wants to go when given a little more room.

[palerider]

try this: http://rs94.pbsrc.com/albums/l105/ldemp ... dleaks.jpg ?

[Pugsy]

try this: http://rs94.pbsrc.com/albums/l105/ldemp ... dleaks.jpg ?

That works. Thank you.

Leak line...better than mine. I would be doing the happy dance for sure if mine was that pretty. I get them on occasion but most of the time I have a least one little less than optimal leak segment.

The pressure line being whacko..fragmented. I think that is the version of Sleepyhead being used. Probably 0.9.5...I had that myself. Version 0.9.6 Windows fixed that issue.

And yes...that little cluster of centrals so near to wake up time is most likely SWJ (Sleep/Wake/Junk)

[Ldempke]

I can't see the graph image....don't know if it is me or your posting.

Regarding pressures and your AHI.
Is that AHI primarily OA and hyponeas? Then yes...maybe a little more minimum pressure and maybe a little more maximum. Probably 1 cm each would do a good job.

Pugsy- image problem was that photobucket changed since I used it last a few years ago. It automatically compressed the image to a blurry mess. I've since uploaded it on dropbox and included a link and will do that from now on in this forum.

To OP
Max leak of 13.2 .....well below large leak territory of 24 L/min even at its worst....if you are mouth breathing any it sure isn't very much and I wouldn't worry about it as long as leaks don't wake you up.

In terms of pressure...looks like you are spending a good bit of time up around 10 ish since the median is 10.6.
I suspect the minimum could stand just a little increase and the OAs should reduce a little. Sometimes when the minimum is more optimally set we see the maximum pressure actually drop or at least not spend so much time up bumping the max line. I think I would probably still increase the maximum a little bit also. See where it wants to go when given a little more room.

Thank you! I will set both number up for tonight and see it how goes. 7 to 12. or maybe 8 to 13? anyways, I will let you know.

and thank you Palerider for helping with my graphs.

PS I do have version 0.9.5 of Sleepyhead. so will update versions. that fragmented line has been bothering me too.

[avi123]

Julie-
Thanks for the thoughts about mouth breathing affecting flow rate. although I tend not to mouth breath much... but that doesn't mean I haven't been with the higher pressure. although my leaks look low on the graphs to me. Here are the graphs:

https://www.dropbox.com/s/2hohxz9xu6ctl ... 0leaks.JPG

so now I am wondering if this graph indicates a decent low leak level? or am I confused and because this is a RESMED 9, it is only graphing excess leakage, and this little purple line in the leak chart is still very bad and needs to be improved?

EDIT: removed poor quality photo that was hosted on photobucket, and inserted link to view image on dropbox.

I see this graph from the dropbox:



Event flags looks OK; Leak is low(good); Pressure graph is chopped, something seems to be wrong with the machine.

On my S9 Autoset I get solid pressure graphs:

[Pugsy]

Pressure graph is chopped, something seems to be wrong with the machine.

Incorrect. It's a graphics problem between SleepyHead and the graphics software on the computer (Windows thing).
Version 0.9.6 of SleepyHead fixed this issue. I had the same thing happen with my S9 reports with 0.9.5 version..but not every S9 user had this problem with 0.9.5. So it's an intermittent problem with some people that is easily remedied and there's nothing at all wrong with the S9 itself.

I will set both number up for tonight and see it how goes. 7 to 12. or maybe 8 to 13? anyways, I will let you know.

Funny about Photobucket...I use it all the time and never a problem. Oh well, no big deal.

When it comes to pressure changes I always like to go up slowly. It makes for an easier adjustment plus we might get lucky and not need as much as we might first think based on the current 95% numbers or median.
Hurts nothing to take just a little time with the increases. If your AHI was double digit we might think more aggressive change but you are real close right now with current settings anyway. Remember we have to remove the Centrals (CAs) from the evaluation process anyway.

If you don't need or want so much EPR then reducing EPR might be an alternative to increasing the pressure and also help with the OAs but if you like EPR then you can just increase the minimum and maximum a bit. Since your starting pressures are relatively low anyway...I would just increase those and leave EPR alone if it were me.

[avi123]

That poster with the S9 Autoset by using SH and relying on it is sure taking a chance.

[Pugsy]

That poster with the S9 Autoset by using SH and relying on it is sure taking a chance.

You are full of it again. Big surprise there. I am also following the new SH data reported with ResScan and guess what? It is pretty much the same and what minor differences I might see are usually rounding up or down differences.
If you don't want to use SH...then don't use it. Pretty simple.

Quit bashing something you don't understand and don't want to understand.

[palerider]

That poster with the S9 Autoset by using SH and relying on it is sure taking a chance.

You are full of it again. Big surprise there.

there's a reason that avi123 is in my 'foe' auto ignore list, I kept seeing irrelevant drivel, or inaccuracy spewed from that id.

[Ldempke]

When it comes to pressure changes I always like to go up slowly. It makes for an easier adjustment plus we might get lucky and not need as much as we might first think based on the current 95% numbers or median.
Hurts nothing to take just a little time with the increases. If your AHI was double digit we might think more aggressive change but you are real close right now with current settings anyway. Remember we have to remove the Centrals (CAs) from the evaluation process anyway.

If you don't need or want so much EPR then reducing EPR might be an alternative to increasing the pressure and also help with the OAs but if you like EPR then you can just increase the minimum and maximum a bit. Since your starting pressures are relatively low anyway...I would just increase those and leave EPR alone if it were me.

I set it to 7 to 12 last night. below is the new picture. (I also changed to SH version 0.9.6 and it took care of the pressure graph problem).
so excluding CA's, the AHI last night was 6.09. I zoomed in close and looked at all the OA's and saw that they started coming when pressure dropped below 9.5 or 10. I sure appreciate your help with this. I can't believe that I just use to wear it and assume everything was the way it was supposed to be.
https://www.dropbox.com/s/gb7y36bsdpusp ... 120526.png

[palerider]

I can't believe that I just use to wear it and assume everything was the way it was supposed to be.

well, in all fairness, that's what you were told to do because you, not being a sleep doctor, are too stupid to know anything... or that's what they'd like us to believe, at any rate