When to change pressure settings?

[threeforward_twoback]

I am starting my seventh week of CPAP. I've read on this board that if your AHI is greater than 5 starting out, you should give it some time before fiddling with your pressure settings. I'm wondering if I need to give it more time, or if I can start experimenting.

Counting up the days of AHI > 5 vs. AHI <5, I've had 16 days where my AHI was above 5.0 (the highest probably being around 7.57) and 26 where it was below 5.0 (the lowest being 1.46, but it seems like the days when my AHI is low are the days I don't sleep very much/at all).

Even so, my numbers aren't where I'd like them to be. Usually if they're below 5 they're a 2 or 3.

I was originally prescribed a fixed pressure of 8 cm. At Pugsy's advice, I changed my machine to APAP mode with min and max both set to 8 cm so I could see my flow limitations. She also recommended trying a range of 8 cm to 10 cm if my AHI still hovered around 5, which it has during four of the past five days since I switched to APAP mode. Should I switch to that range, or do I need to keep trying as it is? Here are my latest stats. Any insight about switching to a range/comments on my data in general would be much appreciated.

[LSAT]

I'll let Pugsy chime in, but personally, I would increase your Max pressure to 12 and see what happens. 8 may not be high enough to stop events.

[Pugsy]

You need more pressure at some times of the night and not so much at other times.
If you do an 8 to 10 range or 8 to 12 range then the machine could/would try to better prevent the airway collapsing with more pressure.

Why do we need more pressure during some parts of the night and not others? Well, usually the 2 main culprits in needing more pressure are supine sleeping or REM stage sleep or maybe a little of both.
Given the bulk of your OAs seem to happen in the wee hours of the morning where we typically have more REM then that would be my primary suspect. It's very common...my OSA is 5 times worse in REM sleep and when I was using APAP I would often see the machine want to go from my normal 10 cm minimum to 16 to 18 cm in probable REM times.

The idea of 8 min and 10 max was to limit the machine from making large pressure changes and get an idea if it wanted to go up...and also give us an idea if maybe you would need a small increase from the 8 cm too. You've been using fixed pressure for so long that I didn't want to add in some big pressure changes (should the machine feel the need to go much higher) just in case those pressure changes disturbed your sleep. So I was being really conservative in my suggested approach for that reason.
Some people find that the least little pressure change can disturb sleep...not everyone but some do and I was just being cautious. I slept right through all those pressure changes during REM but someone else might not be so lucky.

In all honesty I fully expect that the machine will want to go above 10 but I have personal experience with reports similar to yours at 8 cm minimum that even the 8 cm minimum wasn't enough starting point and I ended up with 10 cm minimum. So I have to keep in mind that increasing the max sometimes isn't enough either....but I figure start with easy and obvious and see what happens. If the pressure changes disturb sleep then we have to use more pressure all night instead of just part of the night.
Lots of ways to get that AHI down...your choice as to which way is the way you want to try.
If you want to be super cautious...try the 8/10 range first and see what happens. If you want to be a little bolder try the 8/12 range...if you want to be really bold and see just how high that machine wants to go..try open with 8/20. The machine won't go where it doesn't have a reason to go. It might never go above 12 or it might want to go to 15 or 18. If that gets the job done and you sleep well...then that's great. If you don't sleep so great then we do a little bit of tweaking to limit things so that you sleep good.
The primary goal is your sleep quality...the AHI is the secondary goal because a nice low AHI means nothing if you sleep like crap.

[threeforward_twoback]

If you want to be super cautious...try the 8/10 range first and see what happens. If you want to be a little bolder try the 8/12 range...if you want to be really bold and see just how high that machine wants to go..try open with 8/20. The machine won't go where it doesn't have a reason to go. It might never go above 12 or it might want to go to 15 or 18. If that gets the job done and you sleep well...then that's great. If you don't sleep so great then we do a little bit of tweaking to limit things so that you sleep good.

Understood. Not sure if I will do 8/10 or 8/12 first...either way, should I wait a few days before reporting back? Or maybe a week? Or should I post the first night's report and we can adjust as necessary? I don't want to be too much of a pest!

I also don't want to jump the gun when it isn't necessary, but so far being patient and waiting for things to improve with a certain pressure setting really hasn't gotten me very far.

[Pugsy]

I like to see at least a couple/3 of nights reports at a setting change if at all possible just to make sure we aren't having a fluke night. Plus increasing slowly is usually a little less annoying in terms of adjusting to higher pressures but since we aren't changing the minimum right now...only wanting to see where the pressure wants to go...couple of nights is sufficient in this situation.

I personally would like to see daily reports right now while in this stage of the experiment even if we don't change something each day. Gives me a better feel for how things are going and keeps my memory working straight. That way we can also evaluate how you might feel or might be sleeping because it will be more fresh in your mind. Also if we have horrible results we can back off and re evaluate more quickly.
I don't anticipate any but you never know....
Once we get an idea how things are going and maybe fine tune things...then go to the weekly thing.

[threeforward_twoback]

Thank you so, so much, Pugsy. I really appreciate all the help you give to us newcomers!

I will fiddle with the pressure settings on my machine. I do feel a cold coming on, though. No congestion yet, mostly just chills and a dry throat. My instruction sheet from the sleep center says not to use the CPAP with a cold, but a quick look at past threads here shows that most people still use the machine when they're sick?

I guess I really need to take some Zicam religiously and hope it fights it off! At least enough so that my nose doesn't get stuffed up.

[Pugsy]

I always used my cpap when I had a cold...I found that the humidified air really helped the congestion.
Think how it feels during and right after a hot steamy shower.
If you are horrible sick with a cold though...it slows down the evaluation process a little but we can still get an idea what's going on.

[threeforward_twoback]

So after seeing that the pressure comes in 0.5 cm increments (instead of 1 cm increments, like I previously thought), I did decide to go with the 8/10 cm range. I recall waking up a few times throughout the night, but I was usually able to fall back asleep. Here are my results:

[Pugsy]

That's a good looking report. The machine never really wanted to go anywhere...those spikey things are test pressure probes...normal for apap mode and not related to responding to events.
Except for the little blurp at around 3 AM where it stayed up just a little longer after the probe...the machine felt the need to keep the pressure up a little longer.

So...how do you feel you slept? Any problems?

This is one night...and if you didn't have any major problems I would keep these settings for a few nights to see if it holds true or if this is a fluke night.

[threeforward_twoback]

I think I slept okay. I did wake up a few times but it seemed like I was able to fall asleep pretty quickly. Over the past seven weeks I've noticed that I tend to wake up around 3 a.m. so the fact that the report shows some activity there is not too surprising.

I wouldn't say I feel amazing--most days I feel a little foggy (sometimes I'm foggy all day, and then other days when I feel less and less foggy and right around when I leave work, I feel more alert) and then there tends to be one magical day every now and then where I feel awake all day. I would say today falls somewhere in between. Not too foggy, but not super alert, either.

I look forward to seeing if the new pressure settings make a difference. I will report back tomorrow. Thank you for your help, Pugsy!

[Pugsy]

I wouldn't say I feel amazing--most days I feel a little foggy (sometimes I'm foggy all day, and then other days when I feel less and less foggy and right around when I leave work, I feel more alert) and then there tends to be one magical day every now and then where I feel awake all day. I would say today falls somewhere in between. Not too foggy, but not super alert, either.

I still have all those days...not everything can be fixed with cpap despite our putting all our problems in the OSA basket and expecting cpap to fix it. Wish it were that easy because getting a nice low AHI is really fairly easy....feeling the good numbers though...that's a whole different can of worms.

We have to start somewhere though and getting the therapy optimized is the first step.
Some people can feel a remarkable difference when the AHI is sub 2.0 or higher...some can't tell much of a difference when the AHI varies rather widely. Heck, my first "miracle" day followed a night where my AHI was over 10.0...go figure that one. I didn't check the data until the evening and I thought for sure that I would have AHI 0.0 or close to it...imagine my surprise when it shows 10.something..
I have discovered that sleep quality (as well as quantity) makes a big difference in how I feel no matter what the AHI shows. I have other issues that affect sleep quality and quantity though and those issues are unrelated to sleep apnea...so I continue to have some good days and some not so good and some that are really in the toilet.

If you take any meds...dig deep for potential side effects that either mess with sleep or cause drowsiness or fatigue during the day. It's a common thing and people don't always realize that some of their crappy feeling is related to the meds they take. Maybe not 100% of the blame but meds share part of the crappy feeling blame.

Finally...there is a lot of truth to the "give it time" thing. Your body didn't get this way overnight and it can't be expected to heal itself overnight either. And while you do read of a few lucky people who had the "miracle" right from the start of cpap therapy...those people are really in the minority...most of us took quite some time to really feel much of a difference.

[avi123]

I was originally prescribed a fixed pressure of 8 cm. At Pugsy's advice, I changed my machine to APAP mode with min and max both set to 8 cm so I could see my flow limitations. She also recommended trying a range of 8 cm to 10 cm if my AHI still hovered around 5, which it has during four of the past five days since I switched to APAP mode. Should I switch to that range, or do I need to keep trying as it is? Here are my latest stats. Any insight about switching to a range/comments on my data in general would be much appreciated.

You are making a mistake by taking instructions from members of this board none of whom is a qualified medical respiration therapist. Using Auto CPAP is contra indicated for those who suffer from certain ailments. You need to undergo a sleep study in order to verify if you suffer from these ailments such as Central Apnea, Oxygen desaturation disorder, lack of REMs, COPD, Heart failure, etc.

(Patients with significant congestive
heart failure, chronic obstructive pulmonary disease (COPD), or significant
amounts of central apnea were excluded from many treatment trials of using APAPs
and there is insufficient evidence that APAP can be used to treat these
patients.)
)

[threeforward_twoback]

You are making a mistake by taking instructions from members of this board none of whom is a qualified medical respiration therapist. Using Auto CPAP is contra indicated for those who suffer from certain ailments. You need to undergo a sleep study in order to verify if you suffer from these ailments such as Central Apnea, Oxygen desaturation disorder, lack of REMs, COPD, Heart failure, etc.

Just to clarify, are you saying I may need a third sleep study? These things wouldn't have been caught by the first two?

[palerider]

You are making a mistake by taking instructions from members of this board none of whom is a qualified medical respiration therapist. Using Auto CPAP is contra indicated for those who suffer from certain ailments. You need to undergo a sleep study in order to verify if you suffer from these ailments such as Central Apnea, Oxygen desaturation disorder, lack of REMs, COPD, Heart failure, etc.

Just to clarify, are you saying I may need a third sleep study? These things wouldn't have been caught by the first two?

avi is senile, and rambles... best to put him on the foe list and ignore everything he says.

[Pugsy]

Well...if a person is going to nit pick ...there are contraindications for any pap therapy...not just apap.
I have never seen apap singled out as being bad and cpap being the only therapy that is "safe"
This below is included in every manual out there...and it doesn't say apap anywhere...
All apap is ...is a continuous positive pressure that auto adjusts...that's it. It's a single pressure that auto adjusts and if it was so god awful dangerous then why are all these machines out here and people given a machine in apap mode with settings set to 4/20..
There's NO addendum here to say it's okay to use cpap mode but not apap mode.

We assume that if someone has been prescribed this form of therapy that none of these conditions below are of a concern to the doctor....and since OP here in this thread has had not one but 2 sleep studies...common sense should tell us the doctor is in on the situation.
Even COPD isn't necessarily a bad "no no"...it all depends on how severe the COPD is.

Avi likes to tell people that all apap is bad no matter what just because it is his personal belief...never mind that I have seen his reports where he used apap mode. He also likes to think that only his ideas are worth considering and everyone else's ideas are inferior/dangerous/worthless/whatever.
Mainly I think he just loves to be a thorn in someone's side...which he excels at for sure.