Effects of too much pressure

[Guest]

I have read a few posts where people have adjusted their pressure in increments themselves until they felt good. Has anyone ever unknowingly gone higher than necessary to see if they would feel better only to feel worse? If so would you share your symptoms of too much pressure? Did the AI or HI numbers increase & did that foggy can't do anything feeling come back the next day? I had my setting at 12.0 & felt pretty good but thought that if I would feel even better if I raised my setting to 12.2 cm & ended up feeling pretty bad the next day - my AI & HI numbers also increased. It was only .2 cm which seams negligible, if I was right where I was supposed to be at 12.0 would a slight increase have a negative reaction as described. Why would the AI & HI increase if I had enough pressure to keep my airways open?
Anyway, if anyone can decipher my gibberish I would be curious to hear what other people have experienced.

[Wulfman]

I highly doubt that an increase of 0.2 cm would make any noticable difference. Without knowing any more about what equipment you have and other circumstances, I would guess that if you're wearing a nasal mask, that you're leaking air out your mouth.

Please fill us in on any further information that you can.

Best wishes,

Den

[Guest]

very easy to feel worse increasing pressure too much.

[ozij]

It is actually very easy to feel worse for many reasons that have nothing to do with increasing the pressure.

O.

[Archoliva]

Sorry about the lack of info - I forgot to sign in before writing. I have an elite s8 CPAP by resmed with a FP 431 full face mask. I was diagnosed with OSA 3 years ago and have close to 90 Apneas per hour with an average of 27.5 seconds each. My O2 levels were pretty bad, between 80 and 90 for a third of the study prior to being put on the CPAP for the rest of the night at which time my O2 went up to 95. I was prescribed a pressure of 11.0 cm and felt great for a while. I started feeling bad and got progressively worse over the next couple of years until I reached a point where I could no longer function & thought I had lost my mind (no kidding). I finally put 2 and 2 together and realized my cpap was no longer effective because I was losing air out of my mouth for god knows how long. I went to my dr. who authorized another sleep study after which my pressure was upped to 13.0 cm (different study site and dr. from first). He also recomended sinus surgery as well as surgery for a deviated septum both of which I had. Within a month of the surgery and the 13 setting I could not sleep and felt no better. I then kicked the pressure down to 11 again and increased it in increments of .2 until I got to the 12.2 problem that I described in the earlier posting.
Whew!!! that felt good writing all of that - therapy in a way. Hopefully someone has the energy to read it all and reply.

[rested gal]

I finally put 2 and 2 together and realized my cpap was no longer effective because I was losing air out of my mouth for god knows how long.

How good that you finally identified that particular problem, which is a real treatment buster for so many people. You could have easily become another dropout. Most do not have your determination. Most would conclude "this treatment doesn't work for me" and stop using cpap. Period.

I don't think most doctors or DMEs have a clue about how much problem mouth air leaks can cause in treatment, or how to truly deal with them. Looks like you turned to a Full Face mask, Archoliva.

Having the software to let us take a good look at the nightly leak graph can be quite a real help in identifying that treatment issue. Too bad that most DMEs are interested only in "hours of use" and never even glance at nightly detail graphs....if they ever even do a download at all. Nor are they likely to provide a machine that can record such info anyway.

It is actually very easy to feel worse for many reasons that have nothing to do with increasing the pressure.

O.

Truer words were never spoken!

[cwsanfor]

If so would you share your symptoms of too much pressure? Did the AI or HI numbers increase & did that foggy can't do anything feeling come back the next day?

Funny that you ask, last night I got this result:

http://home.earthlink.net/~wallysanford ... %20for.pdf

http://home.earthlink.net/~wallysanford ... %20for.htm

I think this is a pressure-induced central. I have never had a recorded "NR" before. I have felt like crap all day, which may be anecdotal or coincedental, but in the absence of relevant advice I am going to turn the pressure down 1 cm H2O IPAP, even though the effective pressure did regularly touch the upper IPAP limit.

My settings on the Respironics BiPAP Auto were EPAP 14, IPAP 18.5, PS max, BiFlex 2, HH 1. Mask was the FlexiFit HC431. Leak was a fairly steady 41.

In my effort to hijack this thread, comments are eagerly solicited from anyone, but particularly those skilled in reading charts, including but not limited to -SWS and SAG. I think I know where Snoredog is on this issue, but I welcome his comments, RG's, any BiPAP user, any higher pressure user's, or actually, any user's coments. I may be misreading this result.

I thank you in advance for your replies.

[cwsanfor]

Did that central scare everyone off?

Anyway, I lowered the IPAP to 17.5 and got an AHI of 0.5 (one OA, one H, over about 5 hours).

So I think I've answered my question about needing pressures above 18.

[Archoliva]

Thank you for your thoughts rested gal.
I tried 12cm last night & feel ok.
I have no choice but to keep trying with my cpap - I had two different Dr's tell me that it was a good thing that I was diagnosed when i was because if I had gone a little longer w/o seeking treatment I wouldn't be here now - pretty scary. I would like to say it was strictly determination that kept me "hosed up" but the reality is that there was the fear of not being there for my kids as they grow up. Now it's a matter of trying to stay on top of it & stay in pursuit (as everyone on this board I'm sure is) of that ever elusive good nights sleep. I'm optimistic that with the help all of the valuable information found on this board that it's achievable.
Thanks to everyone who keeps this board running & loaded w/ info!!!!!

[-SWS]

...last night I got this result:

http://home.earthlink.net/~wallysanford ... %20for.pdf

http://home.earthlink.net/~wallysanford ... %20for.htm

I think this is a pressure-induced central. I have never had a recorded "NR" before. I have felt like crap all day, which may be anecdotal or coincedental, but in the absence of relevant advice I am going to turn the pressure down 1 cm H2O IPAP, even though the effective pressure did regularly touch the upper IPAP limit.

Cswanfor, sorry I missed this post when you originally wrote it. Regarding that NR event roughly half way through hours 5 and 6 on your Encore Pro chart. That could very well be a central apnea, and I would even wager to guess that it is. However, the NR category unfortunately does not perfectly document central apneas. Respironics has traditionally employed that NR category to document apneas that were not responsive to three pressure increments above 8 cm. That means any obstructive apneas that do not resolve within three pressure increments also show up in that NR category. And unfortunately any short-duration central apneas (that happen to disappear within the same time frame that it takes the Remstar to implement three pressure increments) do not register under the NR category. Unfortunately, the NR category is not a high-sensitivity/high-specificity indicator of central apneas.

With that said, what I find most interesting about your chart is the near-immediate occurrence of hypopneas presumably after placing the mask back on right around the beginning of the fifth-hour mark. Shortly after that your NR event occured as well. Is that gap a reporting glitch, or did you genuinely interrupt your Remstar therapy session for nearly an hour? There are a few (very few) PAP users who seem to experience a slight pressure-induced string of apnea/hypopnea events (on a non-sustained or transitional basis) as soon as pressure is applied. If I'm reading this rare trend correctly, this occurrence seems just a bit more pronounced in the middle of a prolonged sleep session (perhaps when sleep pressure is comparatively high---thereby significantly decreasing the onset of autonomic breathing immediately after pressure is applied). There is a homeostatic O2/CO2 set-point change that normally occurs for all of us, when we first fall asleep. During this transition the respiratory drive apparently decides to maintain different blood gas respiratory triggers during eupnic breathing. Again, that short-term homeostatic change supposedly occurs in all of us.

However, there may be a few of us for whom the application of PAP machine pressure just may skew that short-term homeostatic adjustment process on a transitional-only basis (versus the sustained CSDB/CompSAS effect mentioned below). If there is any grain of truth to that conjecture, then these rare patients might show a comparative increase of SDB events immediately after the application (or mid-session reapplication) of pressure---if their pressure-skewed homeostatic maladjustment is merely transitional. Unfortunately that's conjecture only, and not established scientific fact.

Patients with CSDB/CompSAS also appear to suffer from a homeostatic maladjustment related to the application of PAP machine pressure. However, those patients seem much more inclined to suffer a sustained homeostatic maladjustment throughout NREM. Allowing for highly theoretical gradients, there just may be some patients for whom that same pressure-induced homeostatic maladjustment is merely transitional (as described in the two paragraphs above). Bear in mind that there is presently no epidemiology that would even support the notion of gradient effects (related to the severity of that same homeostatic maladjustment observed in the much more more overt manifestations of CSDB/CompSAS). These latter hypothetical patients, whose symptoms seem to be largely transitional, just may avoid some transitional homeostatic maladjustment by wearing their masks twenty minutes or so before allowing themselves to fall asleep (I cannot find the medical study where I read that advice). In my way of analyzing, that seems to imply a benefit (for these patients in particular) to allowing the respiratory drive to acclimate to PAP machine pressure before that normal short-term homeostatic blood-gas related change occurs immediately following sleep onset.

[Snoredog]

If so would you share your symptoms of too much pressure? Did the AI or HI numbers increase & did that foggy can't do anything feeling come back the next day?

Funny that you ask, last night I got this result:

http://home.earthlink.net/~wallysanford ... %20for.pdf

http://home.earthlink.net/~wallysanford ... %20for.htm

I think this is a pressure-induced central. I have never had a recorded "NR" before. I have felt like crap all day, which may be anecdotal or coincedental, but in the absence of relevant advice I am going to turn the pressure down 1 cm H2O IPAP, even though the effective pressure did regularly touch the upper IPAP limit.

My settings on the Respironics BiPAP Auto were EPAP 14, IPAP 18.5, PS max, BiFlex 2, HH 1. Mask was the FlexiFit HC431. Leak was a fairly steady 41.

In my effort to hijack this thread, comments are eagerly solicited from anyone, but particularly those skilled in reading charts, including but not limited to -SWS and SAG. I think I know where Snoredog is on this issue, but I welcome his comments, RG's, any BiPAP user, any higher pressure user's, or actually, any user's coments. I may be misreading this result.

I thank you in advance for your replies.

[-SWS]

What I also find interesting about the NR event on Cswanfor's charts is how that NR flagging criteria differs from the traditional RemStar APAP. The traditional RemStar APAP simply implements three pressure increments before recognizing and documenting an event as non-responsive.

By contrast this Auto BiLevel machine has separate IPAP and EPAP pressures to administer. The machine thus sequentially administers three IPAP pressure increments followed by three EPAP pressure increments before the event is designated as non-responsive. No way of knowing for sure if the non-responsive events were central or obstructive, but my understanding is that more central events tend to fall in this NR category than obstructive. I would think reflexive defensive airway closures (productive or counter productive) would tend to fall in this NR category as well. An example of a "counter productive" defensive airway closure would be the type of reflexive closure occurring during the nadir of a CSDB/CompSAS central apnea. An example of a "productive" defensive airway closure would be the same type of reflexive airway closure that defensively and legitimately occurs during a night time acid reflux flare up.

Cswanfor, did you per chance eat or drink anything during that therapy break lasting nearly an hour? Or even within an hour or two of your initial bed time that evening?

[Guest]

Thanks, Snoredog and -SWS. That was an extended potty break. Not real unusual for me, but I have not before or since seen the odd pattern of hypopneas and final NRA like here. I often have the mask off at night, shutting the machine off first. Odd.

Snoredog, I've reduced pressure, and my AHI has lowered, including one 0.0 with the CF2. Thanks for not rubbing it in.

-SWS, I'm going to research this further, and get another titration in Greenwich in a few months to address some peculiarities and unresolved issues.

I also have a PM from SAG, wherein he said to not worry about it. It could have been an artifact or an outlying event, but I did not seem to gain from the higher pressures, so it's all good.

[Snoredog]

[quote="-SWS"]What I also find interesting about the NR event on Cswanfor's charts is how that NR flagging criteria differs from the traditional RemStar APAP. The traditional RemStar APAP simply implements three pressure increments before recognizing and documenting an event as non-responsive.

By contrast this Auto BiLevel machine has separate IPAP and EPAP pressures to administer. The machine thus sequentially administers three IPAP pressure increments followed by three EPAP pressure increments before the event is designated as non-responsive. No way of knowing for sure if the non-responsive events were central or obstructive, but my understanding is that more central events tend to fall in this NR category than obstructive. I would think reflexive defensive airway closures (productive or counter productive) would tend to fall in this NR category as well. An example of a "counter productive" defensive airway closure would be the type of reflexive closure occurring during the nadir of a CSDB/CompSAS central apnea. An example of a "productive" defensive airway closure would be the same type of reflexive airway closure that defensively and legitimately occurs during a night time acid reflux flare up.

[-SWS]

I agree that while your chart is worth trying to understand, it is most definitely not worrisome---based on your event data. None the less, please let us know what you discover all along. Good luck!