Help with Pressure Settings for New APAP User

[el344]

I've been using a CPAP machine for 22 years now and I've benefitted from being a member of this forum for almost all of that time. I currently have an Airsense 10 Elite. My pressure has been fixed at 9 since the beginning. My AHI is consistently under 1. I use an Airfit N30 mask. As far as I am concerned, life with CPAP is easy. So I am spectacularly ill-equipped to help my 86-year-old hearing-impaired husband who is having a very difficult time attempting to use his ResMed Airsense 10 Autoset machine.

He received his machine last week, and originally tried to use a Swift FX nasal pillow mask. He complained that the pillows were painful and that the pressure just kept getting higher and higher until it was unbearable. I called the doctor's nurse for him (telephone conversations are difficult for him) to ask if it would be possible to lower the maximum pressure. She said absolutely not and suggested that he get a full face mask. He was then fitted for an Airfit F20 mask, which he received today.

The mask is a big improvement. He puts on his mask, goes to sleep relatively easily, but he then wakes up complaining that the pressure has become so high that it is causing massive mask leakage and significant discomfort. He is convinced that a lower fixed pressure would work much better for him.

My crash course on the joys of APAP (thanks to this board) suggests that a pressure of 4 to 20 is probably too great a range. I'm going to call the doctor again tomorrow. But I don't know enough to advocate for him effectively.

My questions are:

1. What would it hurt to try a narrower range of pressure? If a lower maximum pressure does not control the apnea, one can always go back up. Is my logic flawed here?

2. If the mask cannot be tightened enough to stop the air from rushing out around the mask, does that mean the pressure is too high or does it mean he needs a different mask? He says the mask is quite comfortable and that he's not having any leakage at lower pressures.

3. If this is the wrong mask, is there any way to determine what might work better for him, short of cycling through the wide variety of full face masks that exists?

4. And what else should I be asking about / suggesting / lobbying for?

His entire experience has been one roadblock after another. This has been a two year journey, mostly because he was unwilling to consider a CPAP machine. Now that he's finally on board, we both desperately want this to work for him. Despite his age and his hearing loss, he's remarkably healthy and active, and I'd like him to stay that way.

Thanks in advance.

[ChicagoGranny]

1. What would it hurt to try a narrower range of pressure? If a lower maximum pressure does not control the apnea, one can always go back up. Is my logic flawed here?

Your logic is good. However, how do you plan on reviewing his nightly AHI to know whether the settings are effective? From a daily report on the machine display? From the recommended OSCAR software?

2. If the mask cannot be tightened enough to stop the air from rushing out around the mask, does that mean the pressure is too high or does it mean he needs a different mask? He says the mask is quite comfortable and that he's not having any leakage at lower pressures.

Youtube has good fitting and adjusting videos for most models of mask. It is recommended to closely watch three or four videos.

3. If this is the wrong mask, is there any way to determine what might work better for him, short of cycling through the wide variety of full face masks that exists?

Nope. Trial and error. But be sure a mask is fitted and adjusted properly before moving to another model. (Like husbands - you have to fit and adjust them.)

4. And what else should I be asking about / suggesting / lobbying for?

He has a great machine (ResMed AutoSet). If you are up to tackling it, the best thing is to use OSCAR and keep coming back to this thread for help.

I admire your patience with a spouse.

[el344]

Thanks for your response.

1. I am planning to use OSCAR. I used Sleepyhead several years ago and found it quite valuable. At this point I only have 4 hours of data.

2. I have watched a couple of fit videos and will watch them with him before tonight. I think the mask does fit pretty well at reasonable pressures.

3. You're absolutely right. Like masks, husbands require trial and error. And it took me two tries to get a good fit.

I may just go ahead and adjust the pressure to something like 7 to 15 to see how he does with that. It's so much easier to ask forgiveness than permission.

[ChicagoGranny]

I may just go ahead and adjust the pressure to something like 7 to 15

It's a better guess than the brainless 4 - 20 factory default that many doctors prescribe.

Hope you enjoy this -

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[palerider]

1. What would it hurt to try a narrower range of pressure? If a lower maximum pressure does not control the apnea, one can always go back up. Is my logic flawed here?

A higher minimum pressure is called for, there's rarely a valid reason for lowering the max pressure. While raising the minimum pressure (which is VERY important technically 'narrows the range', that's not the point. The point is that the minimum pressure needs to be high enough to prevent most apneas in the first place. The max pressure is inconsequential in most cases.

2. If the mask cannot be tightened enough to stop the air from rushing out around the mask, does that mean the pressure is too high or does it mean he needs a different mask? He says the mask is quite comfortable and that he's not having any leakage at lower pressures.

Possibly a different mask, either a different style or a different size. Mask liners can tame the leaks and make them so that they don't bother either you or him while sleeping.

3. If this is the wrong mask, is there any way to determine what might work better for him, short of cycling through the wide variety of full face masks that exists?

Some DMEs will allow you to return masks, or try them out in store. cpap.com has a return policy program for most masks so you can find one that works.

[palerider]

I may just go ahead and adjust the pressure to something like 7 to 15 to see how he does with that. It's so much easier to ask forgiveness than permission.

Don't change the max pressure. Do raise the minimum to 7,

[clownbell]

Bless you for your dedication and perseverence. He's lucky and I hope he knows it.

I am NOT an expert. As a plan ordinary user, I second the comments made by Palerider. When I started out, the minimum setting was 5 -- which I later learned was maybe enough for a teenager but not for an adult. I received recommendations from this board to increase the minimum to 7 and to 8. I did and it made a huge difference. I prefer to ask forgiveness rather than permission. My provider has not made a peep. Either they don't know (haven't looked) or don't care. Do it.

[el344]

Thanks to all who have responded and offered suggestions. I had no idea the minimum pressure was so important, but given the explanations that's logical.

Last night I was able to persuade him to raise the minimum pressure to 5 and he insisted that the maximum be 12. I explained that the minimum needs to be higher to prevent apneas. This morning he agreed to raise the minimum pressure to 6, leaving the max at 12. We'll see how he does.

I've attached his OSCAR graphs. At least an AHI of 18.5 is lower than the 49 he had during his sleep study. But I'm concerned by the number of central apneas. Any further insight will be appreciated.

[Pugsy]

Turn EPR off if at all possible.
If not possible change it to ramp only and make use of the ramp feature....estimate the amount of time it takes to fall asleep.

The goal with turning EPR off is to see if the central apneas reduce or not.

It also effectively increases the overall average pressure which might help a bit with the OAs/hyponeas.

[Pugsy]

Is your husband having very much nasal congestion at all during the night?

Does he take any medications of any kind? If so, what?

Any history of congestive heart failure issues?

[palerider]

Thanks to all who have responded and offered suggestions. I had no idea the minimum pressure was so important, but given the explanations that's logical.

Last night I was able to persuade him to raise the minimum pressure to 5 and he insisted that the maximum be 12. I explained that the minimum needs to be higher to prevent apneas. This morning he agreed to raise the minimum pressure to 6, leaving the max at 12. We'll see how he does.

I've attached his OSCAR graphs. At least an AHI of 18.5 is lower than the 49 he had during his sleep study. But I'm concerned by the number of central apneas. Any further insight will be appreciated.

The centrals *could* be caused by poor sleep, as he drifts in and out of sleep, caused by the pressure being (it seems) *WAY* too low (see how it goes straight up and starts bumping on 'the rev limiter' (Max) all night long?)

[el344]

Here's last night's OSCAR data. The good news is that the central apneas are down. And he says he feels better this morning and that he's getting used to his mask. The bad news is that the obstructive apneas are way up. He had several stretches with no events at all. While I don't necessarily trust Fitbit's analysis of sleep patterns, those stretches correspond to the times Fitbit characterized as deep sleep. According to Fitbit, he got 41 minutes of deep sleep.

We raised the minimum to 7. I'm going up to 8 tonight. He's adamant that we can't raise the maximum pressure, even though he's pegging it much of the night, and that we can't lower the EPR. Small steps, small steps.

As always, thanks for any input.

[Pugsy]

Is your husband having very much nasal congestion at all during the night?

Does he take any medications of any kind? If so, what?

Any history of congestive heart failure issues?

Answers to the above questions please???

Obviously more max pressure (IPAP) is needed and I do understand the reluctance you are fighting. Increasing the minimum isn't going to help all that much because the machine is essentially resetting the minimum to the max and not budging much.

Centrals did reduce somewhat which is good news and like PR said....some of the central flagging could very well be arousal related ...meaning the OAs cause the arousal and the with the awakening/arousal we get the central being flagged.
Arousal centrals we don't worry so much about other than they point to poor sleep. Other than turning off EPR there really isn't much that can be done for the centrals other than if they are indeed related to OAs and arousals we can try to reduce the OAs and thus reduce the chance of arousals which in turn reduces chances of arousal related centrals.

At this point concentrate on what you can do with this machine and that is try to prevent the OAs/hyponeas.
Obviously that involves more maximum. To be honest I wouldn't worry so much about the minimum at this point because once he is asleep the machine is essentially setting a new minimum anyway.....which is the max.
Though trying more minimum might help him get used to the pressures and make him more agreeable to more max.
Anything you can do to get more max is going to be a plus.
Even slow going max increase in 0.2 cm increments.

[el344]

Is your husband having very much nasal congestion at all during the night?

Does he take any medications of any kind? If so, what?

Any history of congestive heart failure issues?

Sorry -- somehow I missed that post. No congestion, no congestive heart failure. Mild COPD, bad silent reflux. Meds: omeprazole, propanolol, cetirizine, simvastatin, Advair, albuterol inhaler, Vitamin D3, B12, Areds, and a probiotic.

I got him to watch ResMed's video on OSA. He seemed to understand what was going on a bit better.

I'll see if he'll go for increasing the max .2 at a time. And he's going to try elevating his bed.

[Pugsy]

Thanks for the additional information. I was mainly interested in nasal congestion potentially being a factor in the machine wanting to go higher. It was a long shot I admit but obviously if his nose isn't congested we can't blame any of that ugliness on nasal issues.

Tell him that with a higher maximum and better prevention of the airway collapses that he should actually sleep through the pressure increases. He probably wants to blame any wake ups on pressure increases when actually it more likely is the OA event that the machine was trying to prevent that was the cause of any arousal.