New here, introduction and some newbie questions...

[FrederickRose]

Thanks, everyone! Here are my data from last night. I put a red box around the time I was asleep.

When I woke up around 3am, I didn't think I could fall back asleep with the mask on, so I took it off. In retrospect, I should have hit ramp instead of taking off the mask. Today I feel like a zombie.

The data shown say min 6, max 20. That's how I started the night, but prior to falling asleep, I had it set to min 7, max 20, so those were the real settings.

To complicate things, I have to take my medical board exam this Wednesday. It's a 10 hour test that I have to take once every 10 years. I don't know whether to wear the PAP the night before that test or stick with the OSA I have been so accustomed to all this time. I guess I'll see how the next couple nights go with PAP.

[Sleeping Ugly]

I see you are taking the "Physician, heal thyself" scripture to heart.

I am a beginner to CPAP--only 2.5 months, but I have been through the same process as you in finding help with optimal therapy. I found that for myself, that raising the minimum pressure incrementally was the ticket to restful and uneventful sleep. I went through a sleep study and doctor/DME combo, but my machine was set for me at 4 min and 20 max. That was WAY too low of pressure for me! I was gasping for air. After educating myself, studying my graph information and through help and advice from some wonderful people here, I have now set my machine at 8.5 minimum and 18 maximum and have definitely hit the "sweet spot." Knowing my own history and reading the other comments, I would also suspect that your minimum pressure is set too low.

Good luck on your journey!

[FrederickRose]

I see you are taking the "Physician, heal thyself" scripture to heart.

I am a beginner to CPAP--only 2.5 months, but I have been through the same process as you in finding help with optimal therapy. I found that for myself, that raising the minimum pressure incrementally was the ticket to restful and uneventful sleep. I went through a sleep study and doctor/DME combo, but my machine was set for me at 4 min and 20 max. That was WAY too low of pressure for me! I was gasping for air. After educating myself, studying my graph information and through help and advice from some wonderful people here, I have now set my machine at 8.5 minimum and 18 maximum and have definitely hit the "sweet spot." Knowing my own history and reading the other comments, I would also suspect that your minimum pressure is set too low.

Good luck on your journey!

Thank you! I'm going to keep advancing the min pressure as tolerated. A little disheartening to see the cluster of obstructive events at 1am when my pressure at that time had been sustained over 10 for a while.

I've got to learn more about leak rate. Also, I'm wondering whether the chin strap I need to keep my mouth closed is contributing to higher pressure requirements by pushing my tongue further back. Lots to learn!

[Pugsy]

Next time you share and image could you omit most of your graphs shown and make the others shown larger so they are easier to view and evaluate?
So it looks more like this image below...
graphs on the right...need
Events
Flow Rate
Pressure
Leaks
If we end up wanting one of those others we will ask.

[Pugsy]

A little disheartening to see the cluster of obstructive events at 1am when my pressure at that time had been sustained over 10 for a while.

I've got to learn more about leak rate. Also, I'm wondering whether the chin strap I need to keep my mouth closed is contributing to higher pressure requirements by pushing my tongue further back. Lots to learn!

Chin straps can alter the jaw a bit if it pulls it back...and maybe narrow the airway a bit. Same can be said of full face masks. Damned if you do and damned if you don't.

Did you ever read my SleepyHead tutorial?
viewtopic/t88983/Pugsys-PointersSleepyH ... Hints.html

What is it about leaks that you feel you don't understand?
Any leak that wakes you up is unwanted even if tiny because it is disturbing sleep.
Now leaks that you sleep through...unless your machine is flagging prolonged large leak times...I wouldn't worry so much about them right now. 15 to 30 minutes of large leak that you sleep through isn't the end of the world.

About the cluster of events at 1 AM when the pressure was at 10?
2 things normally are suspect when we see clusters like that at any pressure...Supine sleeping or REM stage sleep....or maybe both.
1 AM...I suspect REM especially since the cluster really didn't last all that long...about the duration of a REM cycle.

These machines work best by holding the airway open in the first place and they don't increase the pressure in a blink of an eye...hence the more baseline minimum..preventing vs fixing after the fact. The cluster at 1 AM...the machine likely didn't have time to respond to prevent and when each event actually happens the machine sits back and twiddles it's little thumbs while it is happening. After the airway opens up it evaluates things that are going on per the auto adjusting algorithm and will try to make changes accordingly but it doesn't do all this stuff in the blink of an eye so it can't increase the pressure that quickly enough to prevent.
This is why I said you might need more than 10 minimum...for times like this.

Let's gradually increase that minimum pressure (as comfort allows) and see what we end up seeing on the reports with a more optimal minimum in place.

[FrederickRose]

Thanks so much, Pugsy. I skimmed your tutorial a couple times but will re-read it more carefully. I don't think the leaks are waking me up, so I will leave them be for now.

The observation about OSA in REM is interesting. Are there situations where it takes one minimum pressure to treat OSA other than REM-OSA and a significantly higher minimum pressure to treat OSA including REM-OSA? And if so, which is the better scenario?

It seems like there is some uncertainty amongst sleep medicine experts as to the significance of OSA in REM. Ie, whether people who have OSA exclusively during REM benefit from treatment.

[ChicagoGranny]

Are there situations where it takes one minimum pressure to treat OSA other than REM-OSA and a significantly higher minimum pressure to treat OSA including REM-OSA? And if so, which is the better scenario?

I'm not sure what you are asking. Typically, OSA is more severe in REM because the airway muscles are at maximum relaxation. (The hypoglossal nerve may also be a confounding factor.)

My machine pressure settings are 10 - 20. For me, non-REM OSA is well treated at 11 - 12 pressure. REM OSA takes 14 - 15 cm. (Those results are while wearing a firm foam cervical collar to help prevent jaw drop and hold the neck in the optimal position for airway patency. Without the collar, my pressure requirement are much higher.)

BTW, given the point you are at now, I think a sleep lab titration would be a waste of time, money and energy. Many of us have used the sleep lab prescribed machine settings only as a starting point. We use Sleepyhead to find the optimal machine setting.

[Pugsy]

Are there situations where it takes one minimum pressure to treat OSA other than REM-OSA and a significantly higher minimum pressure to treat OSA including REM-OSA? And if so, which is the better scenario?

Gosh yes, I have it myself and I will see if I can dig out some report examples to show you.
I did have an in lab diagnsotic sleep study and titration.
My AHI overall was 12 but in REM 53 and I had desats to very low 70s.
I sometimes need 6 to 8 cm more pressure in what appears to be REM (after 8 years I have learned to spot the probable REM times quite easily).

I came out of the titration sleep study with a RX of 8. But it was the titration study from hell and I slept poorly and only got 6 minutes of REM sleep.
Using my Respironics APAP I self titrated at home and found I was needing 16 to 18 cm at times during probable REM.
With 8 cm minimum it couldn't get to 18 quick enough and couldn't hold the airway open well enough to prevent the collapse in the first place...my AHI numbers were running 8 to 10 to 12. Once I increased to 10 minimum (I went up in 0.5 cm increments) the AHI was cut down to 2 to 4. Acceptable numbers and I left it that way for about 6 weeks with no other changes and it dropped to the 1 to 2 range.

REM worse OSA is very common...and I am a prime example of it.
And yes...it needs to be treated....desats can be brutal even in just REM. I was having massive headaches every morning from the desat imbalance of gases.

Let me go see if I can find an old example to how you. It's been 8 years and the place where I have my old reports is now on my shit list because they want me to pay $400 a year to do what they used to let me do free.

I do wish you had got a ResMed AirSense 10 AutoSet though. Will explain about that in more detail later once you get your minimum worked up to around 9 or 10 and we see the results.

[Pugsy]

Here's one of my old examples. I don't have anything recent in SH.
Encore report...pre SleepyHead days.. Encore was all we had.
I also had reports where there was a significant pressure increase approx 90 minutes after sleep onset when the first REM usually occurs...like the one you see in this report below at the end of the night where we typically have more REM.
I couldn't find an example if it though.
But I think you can get the idea.

[FrederickRose]

ChicagoGranny and Pugsy, thank you very much. The amount of information here is amazing.

I do wish you had got a ResMed AirSense 10 AutoSet though. Will explain about that in more detail later once you get your minimum worked up to around 9 or 10 and we see the results.

I'm looking forward to learning more! Certainly not averse to buying another machine.

[Pugsy]

I'm looking forward to learning more! Certainly not averse to buying another machine.

I have had the opportunity to use both brands and for me in my situation I have done better with the AutoSet.
I have a thread offering my thoughts about it.

viewtopic.php?f=1&t=156279&p=1192307&hi ... t#p1192307

End result...I am using 7 minimum with EPR of 3 with the ResMed and getting the same job done that I needed min of 10 with the Respironics.
The ResMed algorithm responds faster and more aggressively so more pressure when needed faster and thus less need for the higher pressures.

[ChicagoGranny]

The ResMed algorithm responds faster and more aggressively so more pressure when needed faster and thus less need for the higher pressures.

+1

[FrederickRose]

Very interesting. If you can get equal efficacy with less pressure, that seems like a win.

[Pugsy]

Let me say something before all you Respironics users think you have an inferior machine.
For some people the "kinder gentler" response of the Respironics works out better and while it goes up slower...it comes down slower.
ResMed goes up faster but also comes down faster.
And by faster I don't mean 10 minutes difference in response...maybe 2 minutes is all.

Not everyone will see a need for wide variations in pressure needs due to REM or supine sleeping. Some people won't see much change at all no matter what might change.

So for a lot of people they won't necessarily need or want a faster more aggressive algorithm.

There's pros and cons to everything.

[Pugsy]

Very interesting. If you can get equal efficacy with less pressure, that seems like a win.

Yeah..and lord knows I haven't lost any weight that might explain the lower pressures.

The difference between starting at 7 vs 10...in all honesty not a big deal for me but let's face it...lower is a bit more comfortable breathing with....or at least for me anyway.

I have also used various bilevel machines in my experiments. Even used an ASV in both ResMed and Respironics brand.
Found the same thing in terms of pressure with the ASV models.