Getting Frustrated - numbers getting worse

[Tallen234]

I have been on CPAP therapy for a little over 3 months. Early on, I had some serious leak problems that I got ironed out. Right now, I am able to sleep with the mask with no problems and only wake up once a night or so. However, my AI and AHI numbers, which were never stellar, have started to get worse.

Here are the past few nights
Setting min pressure 10 max 19
1/4 - AI - 3.1, AHI 32.10 (95% percentile pressure 12.2)
1/5 AI - 3.8, AHI 31.8 (95% - 10.6)
1/6 AI - 5.2 AHI 31.5 (11.2)
1/7 AI -10.7!! AHI 40.4 (10.4 - VERY WEIRD - lower 95% pressure but more events)
1/8-1/10 - traveling poor compliance

I have had my lower pressure on 10 for over a month - given that my 95% averages over 11, I set up lower pressure to 10)

1/11 AI 3.0, AHI 21.6 (11.2)
1/12 3.8 26 (11.2)
1/13 5.4 29.10 (11.4)
1/14 6.3 26.4 ( 11.0)
1/15 5.0 27.3 ( 11.2)

Throughout November and December, my AI number was a lot better than January, but by AHI was never great (15-25 most nights).

I can't make sense of these numbers, especially given that my autoset should aid in eliminating these events.

Any insights?

Thanks

[track]

I am shooting in the dark here but......Those are way too high. If it was me...emphasize me...I would call the doc...he can't be happy with those numbers. For tonight I would see if I was position sensitive....go buy a ten dollar backpack and wear it to bed for one night or stick a soccer ball under your tee shirt....might get you over the hump until the doc can give you a better suggestion. If you don't have a doc then I would move the lower pressure up another point and tighten the mask so there are no leaks. You have to get those numbers down to under AHI 10 and then AHI 5 or under...sooner better than later. I am sure there will be others that follow me that have better suggestions. Just don't go away..help is coming.

Resmed machines do not respond to apneas when the pressure is above 10...afraid it might be centrals. The only way for apap to deal with the apnea...assuming it is obstructive..is to raise the lower number up.

[jnk]

I think you may need a full night titration study. Auto doesn't seem to be doing its thing for you.

[Wulfman]

A few things come to mind.

Got GERD? There's also a "silent" version.

Using an Auto is NOT working for you. Try straight pressure and see what your numbers look like. I'd start with 10 cm.

Do you have a copy of your sleep study? Any Central Apneas noted?

What was your titrated pressure?

......especially given that my autoset should aid in eliminating these events.

Wrong assumption!


Den

[DreamStalker]

I agree with Den's suggestion ... not everyone does well on APAP mode. Now that you have APAP data, you have a good start for calibrating CPAP mode.

[Tallen234]

Thanks for the quick responses everyone.

A couple of points. I am a side sleeper for the most part. So, I don't think a backpack or soccer ball will help.

My sleep study was a bit weird. I couldn't sleep very well, so I think there was a lot of guess work. I had a full night sleep study and a full night titration. Here is some language from my titration:

The patient was initially started on CPAP at 5 cm of water pressure and was gradually titrated up to 11cm. Initially at 11cm the patient did well, though after nearly an hour of consolidated sleep the patient had an awakening. This was followed by reappearance of central apneas and hyopneas, because of which CPAP pressures were gradually titrated up to 13 cm. At the highest pressure achieved initially, the patient again did not have any breathing events, though toward the tail end of the study scattered hyponeas and Respiratory Effort-Related Arousals as well as central apneas were seen. The central apneas would present after the patient had arousals. Thus it appears that the patient was slightly under-titrated. He did not have much in the form of air leak.....

Recommendations

Based on the findings of the study, the patient clearly benefits from positive airway pressure therapy. At this time, CPAP pressures of 14 to 15cm would be recommended along with Respironics Comfort Fusion nasal CPAP mask, a chin strap as well as heated humidification.

So, based on my layman's understanding, there appears to be some guesswork (more than normal) with his titration recommendations. I am probably going to schedule an appointment with a sleep specialists to see what is going on.

[nomoore]

Since you are still having some trouble with your apneas (AI) lets ignore the hypopneas (AHI minus AI) for now. The Resmed machines will not raise pressure in response to an apnea over 10cm pressure. It will raise in response to other things though like snores or flow limitations. This is because some people start having central apneas over 10cm. Then again, some people don't. From your titration results it looks like you did have central apneas but only following obstructive apneas. It looks like the tech's logic was to raise the pressure enough to prevent the obstructive and then the centrals wouldn't happen either. That sounds good to me. I would try to first bring the min pressure up a little at a time to see if your AI gets better. The hypopneas might be mostly central too and and not caused by the flow limitations that would make the machine raise pressure.

[jnk]

. . . I finally received a copy of my titration study. I know my results were pretty spotty as I barely slept during the study, but they found some interesting results. The titration study said that they recommend "CPAP pressures of 14 to 15". During the study, they never got the pressure up that high. I am a bit worried that they are making some of this up, as I didn't sleep very much during the study. At best it was a flawed study. . . .

Finding out what your AI is at 15 cm in the real world would be interesting. But if you didn't sleep enough during the study for them to find out whether that number should be higher or if that causes you problems, no one knows whether you should be on bilevel, or what. Your titration study should have on it exactly how much you slept. But it sounds to me like a failed study that should be redone--especially if you find, after trying straight 15 for a few weeks, that you still don't get good AI results.

[ozij]

The problem with automatic machines is that they don't learn from experience. Unlike the tech, who figured out you were slightly undertitrated at 13, the machine's thech(nology) is taking back down to the minimum you give it, whenever it can - even though it doesn't seem

I would set the minimum at 12 for a week or two. If that doesn't help, I'd go to 13 minimum.

A second thought: Are you using EPR? That causes your pressure to drop every time you exhale - it will drop below 10. If you are using it, the first step I would take would be canceling that.

O.

[Tallen234]

Yes, I use EPR. That really helped me become compliant. I would hate to give it up. But, I think I have the option to use EPR for the first 30 minutes or so?

A second thought: Are you using EPR? That causes your pressure to drop every time you exhale - it will drop below 10. If you are using it, the first step I would take would be canceling that.

O.

[Wulfman]

Yes, I use EPR. That really helped me become compliant. I would hate to give it up. But, I think I have the option to use EPR for the first 30 minutes or so?

A second thought: Are you using EPR? That causes your pressure to drop every time you exhale - it will drop below 10. If you are using it, the first step I would take would be canceling that.

O.

Sorry. The exhale relief features on the machines is either ON or OFF......for however long the machine is being used.....there's no timer on it like there is on the Ramp feature. (maybe that's what you're thinking about)

Den

[Tallen234]

Hmmm...I just checked the clinical menu, under EPR, it gives three options: Fulltime, During Settling only, Off. Iassume/hope that during settling only will give me what I need....

Yes, I use EPR. That really helped me become compliant. I would hate to give it up. But, I think I have the option to use EPR for the first 30 minutes or so?

A second thought: Are you using EPR? That causes your pressure to drop every time you exhale - it will drop below 10. If you are using it, the first step I would take would be canceling that.

O.

Sorry. The exhale relief features on the machines is either ON or OFF......for however long the machine is being used.....there's no timer on it like there is on the Ramp feature. (maybe that's what you're thinking about)

Den

[Wulfman]

Hmmm...I just checked the clinical menu, under EPR, it gives three options: Fulltime, During Settling only, Off. Iassume/hope that during settling only will give me what I need....

Yes, I use EPR. That really helped me become compliant. I would hate to give it up. But, I think I have the option to use EPR for the first 30 minutes or so?

A second thought: Are you using EPR? That causes your pressure to drop every time you exhale - it will drop below 10. If you are using it, the first step I would take would be canceling that.

O.

Sorry. The exhale relief features on the machines is either ON or OFF......for however long the machine is being used.....there's no timer on it like there is on the Ramp feature. (maybe that's what you're thinking about)

Den

OK. That must be a new feature with the new model......since EPR wasn't even available in Auto mode on the previous Vantage model.

Den

[Tallen234]

Ok, it appears that I have a few option from you kinds folks.


Run auto with EPR off to see if that changes anything

Run straight CPAP at 10, 12 or 15.

Given that I am running Auto at 11 right now, will runing straight CPAP at 10 accomplish anything?

Right now I am leaning toward running straight CPAP at 12.....

[Peaktagger]

I'm with the run it in cpap mode crowd and see what happens.

If leave my APAP with such a wide range, it will always chase snores up to about 15/16, then start chasing pressure induced apneas, hypopneas, NRs, and flow limitations above that, getting worse as the pressure increases all the way up to 20. In other words, APAP will not work for me, like many others. My best AHI is about 16, so leaving it open above that is just asking for more negative events. As my best AHI is about 16, I tend to set a range of 12-16. That way, if the machine is chasing snores, it will be forced to stop before it starts to create pressure induced events at higher pressures. If I don't have a snore problem on a particular evening, the APAP is given a path to lower pressure if it wants to go there, which is good, but is forbidden to blow past 16 on the high end chasing ghosts.

Hope that helps

Michael

Peace