Want to lower AHI further

[vancegate]

I've been using my Intellipap for several weeks and my AHI has stayed around 12. I'd like to get it below 5. It's an auto adjust machine and my average pressure is 17 to 20. I've tried to narrow the pressure range with no improvement. Sometimes I feel like the machine goes crazy on me by maxing out the pressure and not responding to my breathing. I don't notice any leaks, and I've tried 2 different nasal masks. Any advice?

[-tim]

Do you have any info on how long an even is?

For example, 2 15 second events that are 15 seconds apart are better than a single 45 second event but it would show as two AHI events and not one.

How are your events scattered? That can lead to clues on how to fix it. You might have an AHI of close to 0 for hours in your sleep and all the events in one hour.

Can you post any data? Some people on this forum are good at reading the graphs.

[purple]

Low and high numbers for auto should be at least five points apart, according my sleep doc, else the algorithm gets confused about what to do. The more usual issue with newbies is leaks. Leaks are harder to see when the machine is on auto. Usually the recommend of sleep docs is to work on leaks.

I am also guessing you are trying to self titrate without the benefit of having had a sleep study or titration study. Please advise on that as well. If you had an Overnight titration study, then what did the sleep doc recommend?

[vancegate]

Yes I've never had a sleep study. I'm going it alone. A doctor friend of mine gave me the prescription and recommended an apap because he knew I'm traveling a lot for work and couldn't get in for a sleep study.

I haven't bought the $140 software for my machine yet, as I would hate to if I'm going to need to switch. So I have limited data.

I'll post my data in the next post, and start searching for good posts on leaks.

[Heavylids]

Yes I've never had a sleep study. I'm going it alone. A doctor friend of mine gave me the prescription and recommended an apap because he knew I'm traveling a lot for work and couldn't get in for a sleep study.

I haven't bought the $140 software for my machine yet, as I would hate to if I'm going to need to switch. So I have limited data.

I'll post my data in the next post, and start searching for good posts on leaks.

Just when I think I've heard it all. If you haven't even been properly diagnosed by having a sleep study why would you start using xpap? If you machine is maxing out on pressure and you still have high AHI numbers there may be something more to your problems than sleep apnea. My suggestion to you is to MAKE TIME for a sleep study. It could save your life. And your doctor friend doesn't sound like a very good one.

[archangle]

How'd you end up with a setting of 17 to 20? Did you try lower pressures first? Have you seen what happens with a lower maximum pressure?

[49er]

Yes I've never had a sleep study. I'm going it alone. A doctor friend of mine gave me the prescription and recommended an apap because he knew I'm traveling a lot for work and couldn't get in for a sleep study.

I haven't bought the $140 software for my machine yet, as I would hate to if I'm going to need to switch. So I have limited data.

I'll post my data in the next post, and start searching for good posts on leaks.

Just when I think I've heard it all. If you haven't even been properly diagnosed by having a sleep study why would you start using xpap? If you machine is maxing out on pressure and you still have high AHI numbers there may be something more to your problems than sleep apnea. My suggestion to you is to MAKE TIME for a sleep study. It could save your life. And your doctor friend doesn't sound like a very good one.

Heavy Lids,

As an FYI, I had a home sleep study and was diagnosed with sleep apnea. My previous sleep physician set the range from 9-20cm.

I have experienced similar problems with runaway pressure although mine never got as high as 17cm. My AHIs hovered between 5 and 10 while trying pressure ranges of 9 to 20, 10 to 20 and 11 to 20. Narrowing the range would cause what appeared to be centrals.

It was only when I started using a neck collar that my ahi stayed around 2 and I was able to lower the pressure range to 6 to 10. Unfortunately, I haven't been able to sleep the whole night on the machine but that is another issue.

Just because you haven't heard of something doesn't mean it isn't legitimate. I realize that this machine has worked well for most people but I think a very small percentage of us have had this problem.

As FYI, I had a home study due to not having health insurance. To get an adequate titration since I would be a poor candidate for a split study, it would cost at least $7000 in my area.

49er

[jweeks]

As an FYI, I had a home sleep study and was diagnosed with sleep apnea. My previous sleep physician set the range from 9-20cm.

I have experienced similar problems with runaway pressure although mine never got as high as 17cm. My AHIs hovered between 5 and 10 while trying pressure ranges of 9 to 20, 10 to 20 and 11 to 20. Narrowing the range would cause what appeared to be centrals.

Hi,

Here are two issues to consider:

1) a home study works only for the most common and relatively mild cases of OSA. Without 24 channels of data, things like steep states and brain waves cannot be monitored.

2) you appear to be pressure sensitive and are already running at high pressure levels. You most likely need a more complex machines, such as a BiPAP, ST, or ASV.

I was in a similar position some 4 years ago...I had no insurance and the doctor wasn't able to find a treatment that would work for me. The OSA was so bad that I was essentially disabled (couldn't work and I had problems driving). I ended up having 2 somewhat expensive sleep studies at a hospital. Once they got the right machine for me, they were able to very quickly dial into an optimal treatment using BiPAP. While this was expensive, about $7,500 out of pocket, the past 4 years have been, by far, the best 4 years of my life. It is amazing what you can do when you are awake and have energy.

You appear to have a case that is a little more tricky, and your doctor might not be up to the task. You might want to check with the largest cardiac care unit in your area and see if there is someone out there who specializes in complex apnea. Once you make contact, let them know that you are self-pay and that finances are tight. Providers will most often negotiate with you. For example, the first offer that the hospital made for me was 55% off of the list price. I got an additional discount for paying cash in advance and for taking a Sunday night slot.

I hope you manage to get dialed into a good treatment. There is light at the end of this tunnel.

-john-

[49er]

As an FYI, I had a home sleep study and was diagnosed with sleep apnea. My previous sleep physician set the range from 9-20cm.

I have experienced similar problems with runaway pressure although mine never got as high as 17cm. My AHIs hovered between 5 and 10 while trying pressure ranges of 9 to 20, 10 to 20 and 11 to 20. Narrowing the range would cause what appeared to be centrals.

Hi,

Here are two issues to consider:

1) a home study works only for the most common and relatively mild cases of OSA. Without 24 channels of data, things like steep states and brain waves cannot be monitored.

2) you appear to be pressure sensitive and are already running at high pressure levels. You most likely need a more complex machines, such as a BiPAP, ST, or ASV.

I was in a similar position some 4 years ago...I had no insurance and the doctor wasn't able to find a treatment that would work for me. The OSA was so bad that I was essentially disabled (couldn't work and I had problems driving). I ended up having 2 somewhat expensive sleep studies at a hospital. Once they got the right machine for me, they were able to very quickly dial into an optimal treatment using BiPAP. While this was expensive, about $7,500 out of pocket, the past 4 years have been, by far, the best 4 years of my life. It is amazing what you can do when you are awake and have energy.

You appear to have a case that is a little more tricky, and your doctor might not be up to the task. You might want to check with the largest cardiac care unit in your area and see if there is someone out there who specializes in complex apnea. Once you make contact, let them know that you are self-pay and that finances are tight. Providers will most often negotiate with you. For example, the first offer that the hospital made for me was 55% off of the list price. I got an additional discount for paying cash in advance and for taking a Sunday night slot.

I hope you manage to get dialed into a good treatment. There is light at the end of this tunnel.

-john-

Wow John, thank you so much as your advice is timely since I am seeing doctor number two this Tuesday.

I will definitely keep your post in mind when asking my questions.

49er

[vancegate]

Thanks for your concern, Heavy Lids. It appears I do need to make the time for a sleep study. You don't mess with your health, I know. The machine was prescribed by an MD, however, and he did recommend the exact model I got. He works at the VA.

Here is the data my machine gives:

Last 30 Days

• Day Count: 22
  Days at least 4 hours: 22
  AHI: 10.5
  High Leak Flow Time: 0%
  NRI: 0.50
  EPI: 5

Last 7 Days

• Day Count: 7
  Days at least 4 hours: 7
  AHI: 11
  High Leak Flow Time: 0%
  NRI: 0.50
  EPI: 7

Last 1 Day

• Day Count: 1
  Days at least 4 hours: 1
  AHI: 12.5
  High Leak Flow Time: 0%
  NRI: 0.75
  EPI: 8

SmartCode Report Definitions
AHI:Apnea/Hypopnea Index (AHI) represents the average number of apneas and hypopneas per hour for the timeframe.
High Leak Flow Time:Shows the percentage of time where leak was above 95 liters per minute. A value of 10% or more indicates that the mask fit should be checked.
NRI: Non-Responding Event Index (NRI) represents the average number of non-responding events per hour. A non-responding event is a respiratory event that is detected but
by design does not result in a pressure change during AutoAdjust therapy.
EPI: The Exhale Puff Index (EPI) is the number of exhale puff events detected per hour. Exhale puffing is caused by inhaling through the patient circuit and exhaling through the
mouth.

[vancegate]

Thanks for all your advice, everyone. Real helpful. Once I get this ironed out, I'll let you all know.

[-tim]

Based on your numbers and lack of sleep study....

Set the machine for 4->20 (or 5 or 6 -> 20 if your on the heavy side) and get the software.... (people here will send you links).

Your leak data looks very low for the pressure. That implies the mask is strapped down tight which causes other problems.

This just sound wrong.... Hopefuly someone with the software will send you a message. Get that loaded and post the data. Then people can help direct you to the best options.

[Pugsy]

That NRI...would that be like centrals on my machine?
Less than 1 is certainly acceptable.

I don't know what all pressure ranges you have tried. You say you limited the range but you didn't say what the range was.
If you tried to limit around that 9 or 10 minimum it may be too low of a starting point. Have you tried a limited range with the minimum being up closer to your higher pressure average? If the bulk of your apnea events are obstructive in nature and your NRI index stays below 2 or so..maybe try bringing the minimum up closer to the overall average...if you haven't tried that. Now if you have tried that and that is when the NRI index got up a lot higher than 1 or 2...yeah...this type of machine is not working well because you need more pressure to deal with the obstructives and that increased pressure may be responsible for the NRI (if those are centrals).

So..have you tried maybe 13 or 14 minimum and 16 to 18 maximum? If you did...what were the NRI s if they were elevated and what happened to the obstructives?

With any APAP machine...the minimum needs to be close enough to the needed pressure to get the job done effectively. They don't go up in a blink of an eye. They go up in stages and they go down in stages. If the starting pressure is too low the events will come and go before the machine can get up to where it needs to be. This is especially true when people need the pressures that you seem to be needing. Setting at 4 minimum works great if you only need 8 maybe 10 pressure but beyond that it takes way too long for the machine to get up to the effective pressure.

I used APAP....when I used 8 cm minimum my AHI was double digits...when I used 9 minimum my AHI was around 8...when I used 9.5 minimum my AHI was around 5 or 6...when I increased to 10 minimum my AHI dropped below 3...I often saw 18 cm maximum hit pressure on my reports.
Different machine brands may respond a little differently but none of them will increase 6 cm in a blink of an eye and not even within a minute and within a minute...an event can come and go quite easily.

[49er]

Hi Pugsy,

""That NRI...would that be like centrals on my machine?
Less than 1 is certainly acceptable. ""

If I remember correctly and I too tired to look it up, the centrals may be part of the NRI. It isn't a straight correlation although I am not 100% sure on that.

Sorry, due to being tired, I am struggling to communicate clearly so bear with me. To answer your question, 12 was the lowest minimum pressure I used. After I started using the neck collar, I was able to lower the minimum pressure range to 6 to 10 with AHI hovering around 2 with very few NRIs. Of course, not sleeping through the night, I am not sure how valid that data is.

I would love to try your suggestions so I wouldn't have to use the collar but I find anything above 12 very uncomfortable even with the Aflex turned on.

Also, mask leaks aren't as good as I would like them to be even at the low pressure even though according to Devilbiss, I don't have a problem since they don't peg anything as problematic until it hits 95. This is in spite of using the Pad A Cheek liner.

I definitely want a new mask but I am just not sure what to get. Unfortunately, have to stick to full face.

49er

[Pugsy]

I would love to try your suggestions so I wouldn't have to use the collar but I find anything above 12 very uncomfortable even with the Aflex turned on.

So you tried minimum of 12 and maximum of what? and how high did it want to go and what was the AHI?

If your AHI with a 12 minimum and whatever maximum is too high and mostly obstructive in nature then you likely need more pressure BUT if you can't sleep or use more than 12 minimum pressure that really does create a problem.
You may need a Bilevel machine that offers more comfort with inhale and exhale.
You might have done better with a ResMed machine that lets you have a rather dramatic reduction in exhale (up to 3 cm).
I don't know how Devillbiss exhale relief works but I don't think it is that dramatic. It is the difference that allows the comfort. I know it sounds weird but a pressure of 13 inhale with 3 EPR makes it 10 on exhale is easier to exhale against than 10 by itself or 11 or 12. Bilevel machines offer more than 3 cm difference.

I am a bit confused...you mention AFlex which is a Respironics feature yet you show and describe the Devilibiss.
I assume you mean whatever exhale relief the Devillbiss offers. Do they call it AFlex also?
Are you the same person as vancegate who started this thread? Just so I know who is what here. I get easily confused with all the numbers posters here.