New to great board here but need some help Auto Flex

[chaztrip]

Hello,

Some quick background... diagnosed with SA in 2005. Was put on a remstar C flex with a pressure of 9.5. I loved it for the first 4-5 years. I had no problems getting adjusted to it and my energy went up and fatigue went away. Now for the past 2 years or so been having some issues. Because of weight fluxuations they did a tiration study 2 years ago and put pressure at 12. The past 6 months have been real bad and I have been soooooooooo tired again. I am not waking up alot in the night but I am just dead tired. So Doc orders a split study with no sleep aid or anything... I told them I wont be able to fall asleep... long story short I left at 3:00am from the study becase it was not working out. So they decide to put me on a auto pap and see how that goes. I was ready for a new machine anyway so this is my new machine.

Here are the problems and questions I have for you. They start it from a range of 6-20, i tell them that 6 will be too low and I wont be able to breath. They say well give it a try and call the Dr in the am if too low. Of course last night I had the worse night of sleep...... could not get to sleep and when I did I woke a lot. Here are some questions.

I down loaded Sleepyhead and looked at it briefly this am. My pressure never got up over 7.5???? it looked like an EKG and went from 6 to 7.5 First of all is this software OK to use or should I try and find encore to read my data? I went into the machine and verified its set from a range to 6-20. I want to bump up the intial to 8 and try it again to night and see what happens.....

Do any of you have luck with these machines? is it really going to find my correct pressure?? Is there anything else that I should be doing besides calling my dr back?

Thanks!!!!
Chaz

[Pugsy]

Send me a note if you want Encore but I will tell you that it will show the same thing that SleepyHead does.

I used the Respironics APAP until just recently. It will do the job and if it doesn't go above 7.5 then it doesn't sense the need. What were you other numbers reported by SleepyHead? Like the AHI and the breakdown of the AHI components?

Going from 12 down to 6 cm is sure going to feel stifling compared to what you are used to. I found this out when I experimented with higher APAP minimums during my experimenting phase. It is because your body is used to the higher pressure and it perceives the less pressure as "not having enough air moving".
In reality there is enough air moving but it takes a while for the body to readjust to pressure levels that offer comfort.

8 cm minimum will likely feel more comfortable...heck 10 cm minimum might feel even better...basing on how you "feel" with the air initially but if the machine doesn't see the need to go past 7.5 cm....then there isn't any need to go there to fight the events. Now there may be your physical need due to your body needing to adjust to lesser pressure demands. It will adjust with time if you leave the lower minimums or perhaps you could see if 7 cm is more comfortable..if not then perhaps back down from the 12 you are used to. This will take more time than just using the lower minimum now.

[chaztrip]

Here are my numbers from yesterday.... This does not make sense to me as when I was first diagnosed I had over 54 episodes an hour.... now this is showing less then 2? My weight is the same pretty much... but last night was horrible for sleep. Thanks if you say sleepyhead is OK then I will trust you...

Date 1/5/2012
Session Count 6
Start 2012-01-05T13:54:03
End 2012-01-06T06:57:39
Total Time 8:55:29
AHI 1.233
Hypopnea Count 9
Obstructive Count 2
Apnea Count 0
ClearAirway Count 0
VSnore Count 0
VSnore2 Count 1
RERA Count 2
FlowLimit Count 4
PressurePulse Count 21
Pressure Avg 6.24812
IPAP Avg 0
EPAP Avg 0
Pressure 90% 7.5
IPAP 90% 0
EPAP 90% 0

[Pugsy]

This does not make sense to me as when I was first diagnosed I had over 54 episodes an hour.... now this is showing less then 2?

Number of apnea events during the sleep study is really irrelevant. Someone could have 200 events per hour and have them adequately dealt with with a very relatively small amount of pressure.
It is odd that 7.5 seems to do the job when you used to have to use 12 but hey....this is good news.
Your data shows near perfect results and certainly nothing that warrants any increase in that minimum.

That said, your comfort may warrant the increase just so you can sleep comfortably and not feel like you are suffocating. Up to you how you want to address this issue. If it were me I would want to use the lowest setting that I could get by with and sleep well. I might try the 7 cm minimum and if that didn't work go up with the minimum till I was comfortable and then work my way back down slowly till 7 or 8 cm minimum was comfortable to use. You may never be solely comfortable at 6 cm minimum..but then you might.

SleepyHead uses the same data that Encore would pull up. I used Encore for years and still have it on my computer but SleepyHead offers so much more than Encore. I have compared the data from Encore and Pro and it is spot on identical in the areas that Encore Pro or Viewer reports. SleepyHead actually shows data that Pro or Viewer does not report. You can for sure trust that SleepyHead is accurate.
But I will help you get Encore if you need reassurance with it. Personally, not worth the cost for Viewer $100 or the headaches installing Pro (and sometimes it causes great aggravation).

[robysue]

Here are my numbers from yesterday.... This does not make sense to me as when I was first diagnosed I had over 54 episodes an hour.... now this is showing less then 2?

That AHI = 54 was done on a PSG without the CPAP. It's your diagnostic number and it represents what tends to happen when you sleep without a CPAP or APAP.

The SH AHI = 1.23 is your treated AHI as detected by the machine. It represents what's going on during the night when you are using the machine in your own bed.

In other words, CPAP/APAP therapy is highly effective for you in terms of preventing the vast, vast majority of your events. Without treatment you were have problems with your sleep breathing about once a minute. With the current System One APAP, you are having problems with your breathing about once an hour.

Hypopnea Count 9
Obstructive Count 2
Apnea Count 0
ClearAirway Count 0
VSnore Count 0
VSnore2 Count 1
RERA Count 2
FlowLimit Count 4

Given these counts for the various events, it's not a surprise at all that the pressure never increased very much. If you had a cluster of H's or if the two OAs occurred within 5 minutes of each other, that would increase the pressure. But you couldn't have had more than one or two clusters all night long with these figures. Likewise the numbers of VSnores, Flow limitations, and RERAs are so low that there would be little or no increase in pressure triggered by these events.

My guess is that most of the increases in pressure were done as part of the PR "hunt and peck" routine where the machine temporarily raises the pressure to see if there is an objective improvement in the "roundness" of the inspirations in the flow wave data. And seeing no objective improvement, the machine most likely lowered the pressure right back down. That causes the pressure curve to look like a saw tooth wave or a square wave in SH. Which depends on how you have the preferences set up.

My weight is the same pretty much... but last night was horrible for sleep. Thanks if you say sleepyhead is OK then I will trust you...

Lots of things beyond apneas and hypopneas can lead to a horrible night for sleeping. In your case, you said yourself that the pressure setting was so low that you were worried about not being able to breath. You self report that it took a long time to get to sleep and that you you woke up a lot. All of this could easily explain why feel lousy this morning. And, if you were awake for substantial times with the machine running, that could also explain the lack of events. For some of us, wake breathing with the machine tends to trigger a lot of false events, but for other folks it doesn't.

If you are comfortable with the idea going into the clinical menu and increasing that min pressure up to 8cm all by yourself, then do it. My guess is that starting at 8cm may "feel" better and so you'll be able to get more sleep. If 6cm is really effective for you, then running at 8cm should give you similar numbers. As you get used to 8cm, if you wanted to experiment and then lower the min pressure back to 6cm to see whether it is effective in the long run and easier to sleep with, that would be fine too.

Best of luck

[chaztrip]

Number of apnea events during the sleep study is really irrelevant. Someone could have 200 events per hour and have them adequately dealt with with a very relatively small amount of pressure.
It is odd that 7.5 seems to do the job when you used to have to use 12 but hey....this is good news.
Your data shows near perfect results and certainly nothing that warrants any increase in that minimum.

Most of that data is me lying there awake and not sleeping I know this is a process but I am just so bummed out by how tired I have been..... it might all be something else but I want to rule out the sleep first then look at other items.

That said, your comfort may warrant the increase just so you can sleep comfortably and not feel like you are suffocating. Up to you how you want to address this issue. If it were me I would want to use the lowest setting that I could get by with and sleep well. I might try the 7 cm minimum and if that didn't work go up with the minimum till I was comfortable and then work my way back down slowly till 7 or 8 cm minimum was comfortable to use. You may never be solely comfortable at 6 cm minimum..but then you might.

I dont understand how I can go from needing 12 down to 7..... that is why I dont think that this is accurate because of me being awake most of the time? I changed the minimum to 8cm and I will see what happens tonight.

SleepyHead uses the same data that Encore would pull up. I used Encore for years and still have it on my computer but SleepyHead offers so much more than Encore. I have compared the data from Encore and Pro and it is spot on identical in the areas that Encore Pro or Viewer reports. SleepyHead actually shows data that Pro or Viewer does not report. You can for sure trust that SleepyHead is accurate.
But I will help you get Encore if you need reassurance with it. Personally, not worth the cost for Viewer $100 or the headaches installing Pro (and sometimes it causes great aggravation).

From reading more about this I think that Sleepyhead will do fine. Thanks for all the help!!!

[Pugsy]

I dont understand how I can go from needing 12 down to 7..... that is why I dont think that this is accurate because of me being awake most of the time? I changed the minimum to 8cm and I will see what happens tonight.

If you simply did not sleep much last night then the machine didn't have a lot of work to do so perhaps that is why the low numbers...and the low pressure needs. Especially if you happen to be worse in REM sleep and your sleep architecture was so poor last night that you didn't get much REM sleep.

By all means, set the minimum so you are comfortable and are able to get good sleep and then evaluate the numbers. First priority is to get the hours of good sleep. Then evaluate the numbers.

Finally, back to your original problem that caused you to try the APAP in the first place...feeling much less than optimal. If you are able to get good hours of sleep (at whatever pressure) and your data shows that the sleep apnea is well treated then perhaps it is time to investigate other causes besides OSA for the crappy feeling. The machine has a single job...prevent the apnea events. If something else is causing the less than optimal feeling the machine can't fix that. Time to investigate other possible factors like the usual.....hours of sleep, fragmented sleep, meds, pain, other health issues, bed comfort, etc.

A perfect AHI doesn't guarantee feeling perfect.

[chaztrip]

Pugsy and Roby Thanks for the help.

Yes this is my plan to eliminate one step at a time my fatgiue issues. First want to get the sleep right or at least know that the OSA is under controll then look at other items

What about during this "Therapy" time should I have c-flex or a-flex on? on my old machiine I had a c-flex of 3.

Thanks

[Pugsy]

What about during this "Therapy" time should I have c-flex or a-flex on? on my old machiine I had a c-flex of 3.

Either of the "Flex" options and their settings are strictly for your comfort. Play with the settings to see which "feels" best for you. You might prefer CFlex simply because you are used to it.
I tried them all and AFlex at 2 was most comfortable for me. I did try turning it off one night...horrible night. So I didn't do that again.

The Flex option is up to you and how you perceive it. Since you are used to CFlex and if you used AFlex last night then you might find that small of a difference can also impact how well you sleep.

[Janknitz]

Most of that data is me lying there awake and not sleeping I know this is a process but I am just so bummed out by how tired I have been..... it might all be something else but I want to rule out the sleep first then look at other items.

As Pugsy points out, if you weren't asleep, the data is not really indicative of what happens in your sleep. Sounds like you never got to REM. So don't judge the machine on that night alone.

Set it for your comfort and if you are OK with leaving the max at 20 your can titrate from there. If you really need a lower pressure, it won't go up, but if it goes up very high that doesn't necessarily mean you need a higher pressure--you may just need a narrower range because of the machine's slow response time and tendency to "chase" the apneas if set wide open. It will take some tweaking to find the optimal setting and get used to the new algorithm.

[archangle]

Here are my numbers from yesterday.... This does not make sense to me as when I was first diagnosed I had over 54 episodes an hour.... now this is showing less then 2? My weight is the same pretty much... but last night was horrible for sleep. Thanks if you say sleepyhead is OK then I will trust you...

Date 1/5/2012
Session Count 6
Start 2012-01-05T13:54:03
End 2012-01-06T06:57:39
Total Time 8:55:29
AHI 1.233

Where did that list come from? Did you cut and paste from sleepyhead somewhere or what?

[chaztrip]

As Pugsy points out, if you weren't asleep, the data is not really indicative of what happens in your sleep. Sounds like you never got to REM. So don't judge the machine on that night alone.

Set it for your comfort and if you are OK with leaving the max at 20 your can titrate from there. If you really need a lower pressure, it won't go up, but if it goes up very high that doesn't necessarily mean you need a higher pressure--you may just need a narrower range because of the machine's slow response time and tendency to "chase" the apneas if set wide open. It will take some tweaking to find the optimal setting and get used to the new algorithm.

So here is like the 4 nights of data... and I understand that this might take a bit to get to the optimal setting but I am just curious... Look at the numbers below and you can see the first night we can throw out pretty much as it was worthless but then for the next 2, I set the min pressure to be 8 then last night I move it to 9. Is it normal for it to only go up 1.5-2.0 increments to find a pressure like you state above when its "chasing" the apneas? I mean why would not the machine when I had it on 8 as min work its way up to where it was set at 9 min? So does this mean if I set it at 10 tonight its going to climb up to 11 or 11.5? My last tiration was a setting of 12... So I dont know.

Where did that list come from? Did you cut and paste from sleepyhead somewhere or what?

Archangle this is just an export in sleepyhead to a csv file. Its uner the file-export Sorry I did not have notifys on when you replied or would have got back to you sooner

[Pugsy]

then for the next 2, I set the min pressure to be 8 then last night I move it to 9. Is it normal for it to only go up 1.5-2.0 increments to find a pressure like you state above when its "chasing" the apneas? I mean why would not the machine when I had it on 8 as min work its way up to where it was set at 9 min? So does this mean if I set it at 10 tonight its going to climb up to 11 or 11.5? My last tiration was a setting of 12... So I dont know.

I don't quite understand your question about 2.5 to 2.0 increments. Are you talking about the 90% pressure?
If you continually increase the minimum then the 90% pressure has no where to go up also. Till it comes to a point that the machine doesn't do anything except pressure probes in APAP mode so it will continue with 90% increases because in APAP mode there are always going to be the little pressure probes.

I am unclear why you are wanting to go to 12. The whole idea behind an APAP is to be able to use a lower pressure and let the machine increase for the events that might need more pressure.
Based on your AHI....any of your minimum pressures are quite acceptable.

I can't tell how something is trending much by this type of graph. I prefer to look at 3 or 4 nightly details so that I can see when the events might be occurring along with the leak line to see if leak is perhaps a factor in pressure increases.

Based on these numbers...6 cm pressure is sufficient to obtain satisfactory reduction in AHI when using the below 5 standard. 6 cm might not be comfortable and the AHI is a little better with higher minimums and comfort could be enough reason to use a higher minimum. So on paper, any of these minimums is doing the job....so now you look at comfort and/or how you feel.

BTW I wouldn't be changing things based on a single night of data. One needs to make a change and stick with it for a few nights. Your events are well controlled. It is normal to have variations in everything from night to night anyway.

So I am unclear on what your desired goal is here with these changes. I see no need at all to go to 12 just because that was the original RX pressure. Unless for some reason you aren't sleeping well and the pressure changes themselves are disrupting your sleep. If that is the situation then either tighten the APAP range significantly or change over to straight cpap..

[chaztrip]

Pugsy,

I guess I just thought if my fixed cpap was 12... if I had the auto and it was set at 8 min I thought it would work its way up to that. If not then was the re-tiration bogus then when they said 12 was the optimal setting? I understand that I should not mess with it much.... I think that I will drop it down to 8 min and gather the data for that and see how it goes.

[robysue]

Is it normal for it to only go up 1.5-2.0 increments to find a pressure like you state above when its "chasing" the apneas? I mean why would not the machine when I had it on 8 as min work its way up to where it was set at 9 min? So does this mean if I set it at 10 tonight its going to climb up to 11 or 11.5? My last tiration was a setting of 12...

Chaztrip,

Given the entire data set you've posted, I don't think you are looking at the machine "chasing" apneas. I think those 1.5 to 2 cm increments in pressure that show up in the 90% and max pressure numbers are nothing more than the PR's "hunt and peck" algorithm for determining the "optimal" pressure setting to round out the inspiratory part of the wave flow. You can read about that algorithm here on the PR web pages.

Here's why I think what you're seeing is just the "hunt and peck" algorithm in action: The numbers in your table are so small that they indicate that your PR System One is simply not seeing enough apneas, hypopneas, snores, flow limitations, and RERAs to really warrant increasing the pressure very much, if at all. Hence all (or most) of the pressure increases must be due to the "hunt and peck" part of the PR Auto algorithm.


Additional comments about the hunt-and-peck algorithm and what appears to be going on in your data
My guess is that if you look at the pressure graphs in SleepyHead or EncoreViewer, the graph looks mostly like a saw tooth curve: Most of the time it's down at the min pressure, but there are periodic "triangular" bumps where the machine is experimentally increasing the pressure by either 1.5 or 2cm to "test" whether the shape of the inspiratory part of the flow wave improves. If the flow wave does improve at some point, the pressure is "re-set" to that level, and you see a linear increase followed by a flat line at the new pressure setting in the flow wave. But your flow wave is already pretty decent (as the low numbers of FL, RERAs, snoring, OAs, and Hs indicate). And so little or no improvement is found when the machine experimentally increases the pressure. And so most of the time, you are probably seeing a full saw tooth in the pressure graph and at the end of each sawtooth, the pressure is back down to the minimum pressure setting.

Now the thing is, each of these "test bumps" from the PR "hunt and peck" algorithm takes about 5 minutes to complete and the machine will run through these "tests" at a rate of about 6 per hour---in other words, the next text starts about 5 minutes after the last test ends. And that's enough time at the higher pressures to be reflected in the max pressure setting (the tops of the bumps) and the 90% pressure setting (which turns out to be about 3/4 of the way up a bump, if I recall correctly). But since half the time is spent at the minimum pressure setting, the average pressure setting is much more influenced by that min setting than the pressures reached during the top of the sawtooth bumps. That's why your "average pressure" in SH is so close to the minimum pressure setting each night.

And my guess is that if you set the minimum pressure 10cm, then yes, the tops of the sawtooth test bumps would be at 11.5 or 12cm. And if you were to set the minimum pressure at 12 cm (your titrated pressure), the tops of the sawtooth test bumps would be at 13.5 or 14 cm.

Like pugsy, I'm puzzled about why you think you need to increase the pressure just because your titrated pressure was 12cm. The presented data indicates that you're doing fine (in terms of preventing the apneas and hypopneas) at the low pressures the machine is currently using: These are great numbers. And so the real question is how do you think you are sleeping and how do you feel in the daytime. If the pressure changes due to the hunt and peck algorithm are bugging you (and they do bug some people), then switching to straight CPAP at 8cm might help you sleep better. If you do decide to switch to CPAP, then leave it at a given setting for a week or so before making any further adjustments based on the data.

"Chasing events" behavior
When a machine is "chasing events" on the other hand, the problem is that a cluster of OAs and H's occurs (because the pressure is too low), so the machine reacts by increasing pressure (but not with enough of an increase if the min pressure is not high enough), and so the events continue to occur, and the machine reacts by increasing the pressure even further. The vicious cycle cluster of events followed by pressure increases continues to occur---possibly to the point where the pressure is much higher than the person actually needs on a nightly basis because once our breathing gets really ugly, it can take a lot to manage to try to get it back under control. But a proper min pressure level will be high enough to prevent most clusters from happening in the first place AND when the first cluster starts, the first increase in pressure is enough to break it up and get the wave flow data smoothed out and nice and round instead of allowing the breathing to stay rather ragged, and hence, when the min pressure is high enough, the first pressure increase is enough to break up the cluster of OAs and our breathing never deteriorates to the point where it's really, really ugly. In other words, pressure increases due to chasing events occur when the machine responds too late and with too little initial pressure to bust things up before stuff really gets ugly. And once the breathing does get ugly, it's even harder to "fix" and that requires more pressure than it would have if the starting pressure had been higher to begin with.