CPAP Therapy Analysis & Settings Advice..please!

[WW4B]

Hello and glad to be part of this forum. It has been awhile since I have last visited or posted. Having major issues using CPAP therapy and looking for advice on my charts. I have included several random charts with different settings in trying to fine tune my therapy and recognize where my issues lie. Large leaks seem to be a major issue and being a side sleeper using the Dreamwear nasal pillow mask is not helping the issue. The charts with the January dates have the trigger and cycle settings set to very high. The earlier dated charts have the settings set to the default settings with lower IPAP/EPAP/PS settings. There are also times that I feel that the breathing cycle when inhaling could/should be longer. I feel that I want/need to be taking deeper or longer breaths. Would my charts indicate that this is happening? Would I benefit by changing trigger and cycle settings back to the default settings or changing/increasing the Ti min/max settings? Have been reading and absorbing so much on the subject that i am getting myself confused and overwhelmed on what is the right or the more correct approach to fine tune my therapy and feel refreshed when waking. Also have been waking up with a severe dry mouth. Would I benefit with a lower PS setting? Lower or higher IPAP or EPAP settings. Can someone please offer their advice, guidance and wisdom. Thank you all in advance

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[robysue1]

WW4B

The first thing I would encourage you to do is to slow down on making multiple changes all at one time. When things go wrong and you've changed multiple settings it is hard to figure out which setting is the one causing the problems.

You write:

The charts with the January dates have the trigger and cycle settings set to very high. The earlier dated charts have the settings set to the default settings with lower IPAP/EPAP/PS settings. There are also times that I feel that the breathing cycle when inhaling could/should be longer. I feel that I want/need to be taking deeper or longer breaths. Would my charts indicate that this is happening? Would I benefit by changing trigger and cycle settings back to the default settings or changing/increasing the Ti min/max settings

While the AHI is better with the higher settings for settings min EPAP and PS, it's hard to say just from a couple of random nights whether you're making progress or not. If all you were asking about was leaks and AHI, then discussing the changes to those settings would be meaningful.

But what's troubling me is that you are also indicating that you've changed the Trigger and Cycle settings and that now you are feeling like the machine is not totally in sync with your breathing. In particular, you say that there are times when you feel like "inhaling could/should be longer." In other words, it sounds to me like there are times when you think the machine is prematurely reducing the pressure from IPAP to EPAP.

I'm assuming this sensation has gotten worse since you changed Trigger and Cycle. Is that correct?

There are two settings that might be responsible for the machine prematurely "cycling" from IPAP to EPAP before you are done with your inhalation when you want to take a deep or longer breath. One is Cycle. The other is Ti_Max.

By changing Cycle from Medium to Very High, you have caused the machine to cycle from IPAP to EPAP earlier in the breath cycle---and this cycling from IPAP to EPAP may be happening before you feel like you are done or almost done with your inhalation. Out of curiosity, why did you make the decision to change Cycle from Medium to Very High in the first place? In any event, I would recommend changing Cycle back to Medium.

It is also possible that the default setting for Ti_Max is too low. If Ti_Max is set to 1.5 seconds, then the machine will cycle to EPAP 1.5 seconds after the beginning of your inhalation. If you are not done inhaling you might very well notice the drop in pressure and it could feel like the machine is either encouraging you to exhale. Or it could feel like all of a sudden there's not enough air coming in through the mask to comfortably finish your exhalation. I would strongly recommend setting Ti_Max to its maximum setting of 4 seconds.

There's also a possibility that changing your Trigger setting to Very High may also be causing you to feel like you can't get enough air for a really deep, satisfying inhalation. The problem when Trigger is set to Very High is that this can delay the machine from changing from EPAP to IPAP when you start inhaling. The rate of inhalation has to be greater to trigger the switch to IPAP when Trigger is set to Very High. And that means as you just barely start your inhalation, the pressure is still at EPAP and that could trigger a feeling that there is not enough air coming into the mask for a deep, satisfying inhalation. I would recommend changing Trigger back to Medium.

Finally, I would leave Ti_Min alone. The Ti_Min setting is the minimum amount of time before the machine is allowed to cycle to EPAP when it detects an inhalation. If Ti_Min is set to 0.5 seconds, then the machine will NOT cycle to EPAP for at least 0.5 seconds from the start of your inhalation if you start exhaling before the 0.5 seconds has elapsed. In other words, if you start exhaling 0.25 seconds after your inhalation started, the machine won't cycle to IPAP for another 0.25 seconds when Ti_min = 0.5.

As far whether there might be something in your charts that corresponds to when this is happening, my guess is that there is not anything obvious that will clearly hit you over the head unless you zoom in so far that you can see no more than 3 or 4 individual breaths and you compare what's going on in the Mask Pressure graph to the flow graph. In that case you may be able to see where the machine is "triggering" the increase from EPAP to IPAP and where the machine is "cycling" from IPAP to EPAP. But it's not going to be very precise and if the breathing you are looking at is not particularly regular it can be difficult to see the connection.

To show you what I mean: I currently have my own Trigger and Cycle set to either High or Very High (not sure which) specifically because I have had the opposite problem you are reporting: When I was a newbie, I often felt like the machine was increasing the pressure to IPAP before I was done exhaling, and this prevented me from exhaling fully and completely. I also would sometimes struggle to start my exhalations. Here is a very zoomed in marked up snippet of some of my sleep breathing with red lines indicating when the machine decided to "cycle" to EPAP and black lines indicating when the machine decided to "trigger" the increase to IPAP.



As you can see, when Trigger is set to High or Very High, it delays the increase from EPAP to IPAP until after the inhalation has clearly started. When Cycle is set to High or Very High, it causes the machine to start the decrease from IPAP to EPAP before the inhalation is completely over.


You also write:

Have been reading and absorbing so much on the subject that i am getting myself confused and overwhelmed on what is the right or the more correct approach to fine tune my therapy and feel refreshed when waking.

My advice is to go slow. First identify a specific problem you are trying to fix, such as the fact that you sometimes feel like the machine is preventing you from being able to take deep, satisfying inhalations. Change one variable at a time or at most, a set of variables all of which are related and all of which address the specific problem you are trying to address. Then use the new settings for at least 4 or 5 days before changing them again. (The one caveat is if the change leads to a clear disaster---then go back to your previous settings.)

Once you have the first specific problem fixed, then identify the next problem you need to fix that involves playing with the therapy settings. And again, make one change at a time.

Yes, the "go slow" approach requires patience. And you probably won't feel much difference on the first night or two. But the problem with changing too many things at one time or changing settings every night or two is that it can be impossible to figure out what is "working" and what is "not working" in terms of making this crazy therapy work for you.

Also have been waking up with a severe dry mouth.

Dry mouth problems are usually related to leaks and/or air getting into the oral cavity rather than the pressure settings. The leaks do not need to be large enough to be flagged as "large leaks" and if your mouth is not opening, but air is still getting into the oral cavity, you might not even have any leaks at all.

Suggestions on what to do for severe dry mouth problems include:

• Increase the humidifier setting, particularly if you are not dealing with rainout issues.
• Work on fixing any leaks, even if they seem to be minor in Oscar.
• Pay attention to whether your mouth is opening and/or your tongue is dropping down from the roof of your mouth. These are the things that allow air to be blown through your nose and wind up inside your oral cavity. Pay attention to where you keep your tongue when you are awake and not talking or eating or drinking: If it doesn't naturally stay touching the roof of your mouth and the back of your top front teeth, try training it to park itself there. If you can keep it there during the daytime, it might stay there during the nighttime as well.
• Keep yourself well hydrated, use Biotene mouthwash and/or XiliMelt tablets to help relieve the dry mouth symptoms, and keep a water bottle by your bed so you can drink water if you wake up in the middle of the night with a parched mouth.

Would I benefit with a lower PS setting? Lower or higher IPAP or EPAP settings.

I honestly don't think changing the PS setting or the Min EPAP or Max IPAP settings is going to do anything to fix your dry mouth problems or the problem you have with feeling like you sometimes can't get a satisfying, deep, long inhalation because the machine cycles to EPAP before you are done inhaling.

[WW4B]

robysue1
Thank you for the reply and a better explanation on the meaning of the Trigger, Cycle and Ti settings and what they do and/or accomplish.
I think I may have been experiencing what you were experiencing in regards to trigger and cycle which is why I tried them with the settings set to high or very high. It has been hard to differentiate whether the machine was increasing the pressure to IPAP before I was done exhaling, and this prevented me from exhaling fully and completely or do I have the need to have deeper/longer inhalations ..or both, if this makes sense. nI also would sometimes struggle to start my exhalations. And..No, not really did my breathing cycle sync get worse with the trigger and cycle set to high or very high!
Like you mentioned, I believe I am getting confused and frustrated and trying too many things to soon and all at once.
Therefore, I will go with your suggestions to return trigger and cycle settings back to to medium and try Ti_Max to the maximum of 4. Ti_ Min is set to the default of 0.3, would you recommend setting it to 0.5 or leave as is?
Given what you see, what would you recommend on the IPAP, EPAP and PS be set to. Would you lower any of these settings?
In regards to dry mouth, will set the humidifier higher, stay hydrated and have been practicing to train on keeping my tongue touching the roof of my mouth and the back of my top front teeth as well as fitting my mask better to eliminate leaks. May try a mask other than a nasal one.
Thank you so much for your help and advice...

[WW4B]

Very appreciative of the advice and guidance given. May I please ask for advice and/or additional analysis. Two additional recent graphs are attached. Question...with my 95% pressure settings numbers around 10 and 14 would it be more beneficial if I switched min Epap min settings to 6-7 / max 20 and lowering PS to 3 or 3.4 range.
All other settings are Trigger = High,Cycle = Med, Timax = 3, Ti min = 0.3. Also how do my flow limitations look ?
Thanks.

[robysue1]

Very appreciative of the advice and guidance given. May I please ask for advice and/or additional analysis. Two additional recent graphs are attached. Question...with my 95% pressure settings numbers around 10 and 14 would it be more beneficial if I switched min Epap min settings to 6-7 / max 20 and lowering PS to 3 or 3.4 range.

Personally, I would not switch the current settings if my data usually looked like these nights and I was feeling OK.

Lowering your Min EPAP from the current 10 to 6 or 7 will increase the chances that events will occur before the machine increases the pressure to where you need it to be. Lowering the Min EPAP to 6 or 7 is may also increase the flow limitations and may allow some snoring to occur.

So unless there is something specific that you need to work on fixing in order to increase your comfort and your overall sleep quality, your current pressure settings are doing an excellent job of fixing your obstructive sleep apnea.

In other words, we're back to the question I first asked: What specific problems are you trying to fix with the dial winging?

If you are not waking up feeling relatively rested, you need to consider other non-apnea-related causes of bad sleep instead of just doing the dial winging hoping to stumble on some "magic" combination of settings that fixes everything.

All other settings are Trigger = High,Cycle = Med, Timax = 3, Ti min = 0.3. Also how do my flow limitations look ?

Did the new settings for Trigger, Cycle, Ti_Max, and Ti_min fix the problem of feeling like you could not always inhale as deeply and as fully and as long as you wanted to inhale? That is a critical problem to fix in order for you to be able to comfortably get to sleep and stay asleep while using the machine.

As for your flow limitation graph: In my opinion it's acceptable, but not "great". In other words, if you are sleeping well and waking up rested and havre enough energy to get through the day, you don't need to worry about eliminating that last little bit of activity on the flow limitations.

But if you are not sleeping well, you need to do some digging: Are there other non-apnea related things that could be causing the problems with your sleep? If so, work on those issues first. If not, then it may be worth doing a tiny bit of dial winging with the PS settings. But at this point? I'd say stick with the current settings for at least a week or two before doing any more dial winging as long as you are now able to inhale as deeply and as fully and as long as you want to when you're wanting to do a deep, long full relaxing inhalation.

[WW4B]

Thank you robysue1 for the reply and your very knowledgeable input. Things are getting better and are much improved with the recommended settings you advised put in place. Comfort is much better but overall sleep quality still leaves me in a bit of a fog, it seems, as the day goes on. Will leave things as they are unless you have any other "tweak" recommendations to try. I am still trying to learn how to interpret reading my graphs but still need help and guidance to clarify what they mean and are displaying. So...In regards to my flow limitations graph not being great but acceptable, what is it that it is showing or not showing in regards to being better? Are there any tips or recommendations you can advise on making the flow limitations display better readings. Thank you.

[Pugsy]

If you want to see what a non problematic flow limitation graph looks like then take a peek at mine below.
I have never had flow limitations of any significance unless I happen to have a cold and/or some nasal congestion...which is rare.
Nasal congestion can make FL graphs look a bit ugly.

FWIW I agree with RobySue.....if I was feeling good and sleeping good then I wouldn't worry about the relatively minor activity on your FL graph.

Here's my FL graph.



Now if you want to compare yours to a really "bad" FL graph you can see this one below...BTW this person was experiencing a LOT of nasal congestion. More pressure isn't the fix for an active FL graph that is caused by nasal congestion.

[WW4B]

Thank you Pugsy and.....Yikes on the comparison of flow limitations graph. Kind of puts it into perspective that mine isn't as bad as i imagined. As a person with a partially deviated septum I am always have that congested feeling whether sitting, standing or sleeping. I would love to be able to breathe fully through my nose through both sides of my nostrils. It is one reason that I change the settings as much as I do. I have noticed that since I have changed my hose, cleaned up the machine/humidifier/filter and switched my Dreamwear headgear to the "headgear with arms" my leak rate as gone down to a 95% weekly average of 1.45l/min from 22.80l/min previous 60 day average as well as with better overall breathing and comfort with the settings advised by robysue1 put in place. I have attached several charts in this post with differing pressure settings along an attached post in this reply from last night to see what the effect they would or may have on my charts and sleep. Small sample size yes, but I have not noticed any substantial benefit in any one change and that is how I seem to learn best and was hoping my charts would reflect the best option in settings. Now lastly, if I may, can I please ask with what you see in my 95% pressure settings as per all of my attached charts in this post would you recommend I go with for the next 2-4 weeks after which I would love to post the results in a month for a review and as a progress report. My max Ipap has always been 20-25. Min Epap has ranged from 7-11.2 and PS has ranged in 3 - 5. What you recommend I stick with for the next couple of weeks. I cannot thank you all enough....
Have a blessed day!

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[Pugsy]

Did you notice my settings in my report I shared above.
I use the AirCurve 10 VAuto in auto mode and my settings are
EPAP 5
PS 4
max IPAP 25 which I never ever come close to achieving so I don't care what the max setting is. The max setting is a moot point if you never reach it. Contrary to what some people think the max setting doesn't alter the overall algorithm function for therapy.

I don't see any urgent need to change anything in your reports.
BUT as someone who sometimes changed stuff, just because I could and I was curious, you are of course free to do the same.
I don't see it harming anything and you will probably learn from the experiment.
I once worked my minimum EPAP up to 13 just to see what would happen. I went up slowly 0.5 cm at a time over a period of time.
and nothing at all changed. Quality of sleep didn't change. Hours of sleep didn't change. General daytime feelings didn't change either.
AHI didn't change. Nothing changed at all. Sometimes all you learn is nothing changes.

So the fact that you are curious is probably a good enough reason to experiment but I don't see any urgent need at this point.

Do expect variations in data recorded from night to night. We simply don't sleep the same each night.

If you want to experiment you have to remember keep your variables to a minimum and meticulously keep a log as to your results both the data from the machine and how you sleep and feel overall.

[WW4B]

Thank you....But, if this were you, where or what would you recommend my staring point be for PS and EPAP.

[Pugsy]

Thank you....But, if this were you, where or what would you recommend my staring point be for PS and EPAP.

It would all depend on what my goals were. What I expected to learn or wanted to change or if I was having something I wanted to fix or eliminate because it caused a problem.

At this point I tend to lean towards "if it ain't broke don't go trying to fix it".

If you change anything....do only ONE change at a time though. Example....Don't go changing minimum EPAP and PS at the same time.

Your max IPAP setting....doesn't matter what it is. It is a non factor at this point.

Now the humidity setting may or may not be something to also consider playing with given your sometimes nasal issues.

[robysue1]

Thank you Pugsy and.....Yikes on the comparison of flow limitations graph. Kind of puts it into perspective that mine isn't as bad as i imagined. As a person with a partially deviated septum I am always have that congested feeling whether sitting, standing or sleeping.

In that case, you may never have a perfect flow limitation graph like Pugsy's. In other words, don't sweat trying to improve your already reasonable and acceptable flow limitation graph since it's likely to never happen anyway.

I would love to be able to breathe fully through my nose through both sides of my nostrils. It is one reason that I change the settings as much as I do.

There's a thing called the nasal cycle that affects many normal people: The fact is that many people will breathe primarily through one nostril at a time while the other one can feel congested. Oftentimes, the nostril that the person breathes through switches every 25-30 minutes or so. And many of us are not even consciously aware that we're breathing through one nostril unless we wind up "blocking" the congestion-free nostril for some reason. You should google "nasal cycle" for more information.

And the frequent changes of therapeutic settings may be adding to your congestion problems: Many noses don't like constantly changing conditions and you're not allowing your nose to get used to the feel of CPAP when you keep changing the settings.

I have noticed that since I have changed my hose, cleaned up the machine/humidifier/filter and switched my Dreamwear headgear to the "headgear with arms" my leak rate as gone down to a 95% weekly average of 1.45l/min from 22.80l/min previous 60 day average as well as with better overall breathing and comfort with the settings advised by robysue1 put in place.

It sounds to me like the change in headgear is probably the most significant factor in your decreased leaks. The changes I suggested may be what's led to overall better breathing and comfort.

I have attached several charts in this post with differing pressure settings along an attached post in this reply from last night to see what the effect they would or may have on my charts and sleep. Small sample size yes, but I have not noticed any substantial benefit in any one change and that is how I seem to learn best and was hoping my charts would reflect the best option in settings.

Charts are useful for determining that something is clearly wrong. But they're not as useful when it comes to definitively saying that the settings have been optimized.

There is nothing in the data that you posted for last night that screams, "This needs to be fixed!" In other words, as far as the objective data recorded by your machine is concerned, these settings are probably as good as any in terms of treating your OSA.

So you need to be asking the questions: Why is my sleep not yet good sleep? And what can I do to make my sleep better?

And the answers to those questions may involve things other than your CPAP settings. In particular, what does your sleep hygiene look like? And do you have any other medical conditions that can adversely affect the quality of your sleep? And are you on any medications that can adversely affect the quality of your sleep? And finally, silly as it sounds, are you simply worrying so much about the quality of your sleep that you aren't able to get good quality sleep even though your apnea is well treated?

Now lastly, if I may, can I please ask with what you see in my 95% pressure settings as per all of my attached charts in this post would you recommend I go with for the next 2-4 weeks after which I would love to post the results in a month for a review and as a progress report. My max Ipap has always been 20-25. Min Epap has ranged from 7-11.2 and PS has ranged in 3 - 5. What you recommend I stick with for the next couple of weeks. I cannot thank you all enough....

In all seriousness, I don't think it much matters if you set Max IPAP to 20 or 25. You aren't getting much above 15cm of pressure on any of the nights.

As for Min EPAP, I'd be inclined pick a number and then stick with it for several weeks. Your posted data with Min EPAP between 9 and 10 seems to give nice low AHIs and reasonable flow limitation graphs. The question is whether you are comfortable starting the night out at 10cm. If so, then that's where I'd set min EPAP and I'd leave it there for at least 2 full weeks. If you are not comfortable starting the night out at 10cm, then I'd suggest using 9cm or whatever the maximum Min EPAP you are comfortable starting the night with as the min EPAP setting for the next two weeks.

In terms of PS, again, I think the actual value you pick for PS is less important than finding the discipline to leave the setting alone for two weeks. Since a few people do have problems with pressure induced CAs when the PS is too large, I'd recommend sticking with PS = 4 for now.

In other words, if you want my advice, I'd set your machine's therapeutic pressure settings as follows:

• Max IPAP = 20
• Min EPAP = 10, as long as you have no trouble getting to sleep when your EPAP pressure starts at 10cm
• PS = 4

And then I'd work super, super hard on resisting the urge to keep changing the pressure settings every few nights. Gather at least two weeks of data. And you need to gather some subjective data in addition to the objective data recorded by the machine and shown in Oscar. I would strongly suggest that you keep a simple sleep log during the two weeks that you do NOT change the therapeutic settings. Here's the subjective data I think might be of use to you, along with simple 0-5 scales for measuring them, where appropriate:

• Time you went to bed for the night.
• Time you got out of bed in the morning.
• Estimated time asleep during the night. Don't try to measure this---just give a gut instinct guess. If you felt like you tossed and turned for about an hour, then your estimated sleep time is time in bed minus 1 hour. If you don't remember any wakes and you got to sleep quickly, then your estimated sleep time is basically equal to your time in bed.
• Restlessness and possible wakes during the night: 0 = little or no restlessness and no wakes to 5 = lots of restlessness and numerous wakes that you remember in the morning
• Ease of falling asleep: Either estimate how long it took you to fall asleep at the beginning of the night OR use a scale where 0 = less than 10 minutes to 5 = well over 45 minutes.
• Night time congestion: 0 = little or none (much better than you usually experience) to 5 = really bad congestion (worse than you usually experience)
• Feeling on wake: 0 = well rested and great to 5 = horrible and exhausted
• Tiredness & sleepiness during the day: 0 = plenty of energy and little or no sleepiness to 5 = exhausted and sleepy all day long

Everything except the rating on tiredness & sleepiness during the day should be filled in shortly after you wake up. The rating on tiredness & sleepiness during the day should be recorded near bedtime.

If you have other medical issues, such as night time pain, that interfere with the quality of your sleep, you might want to add that to the data you are gathering for a couple of weeks. Likewise, if you take medication near bedtime you might want to make a note of that. If you eat very close to bedtime, that can also affect your sleep, as can alcohol consumption. So those are also things you might want to make notes about.

Once you have some subjective data as well as a couple of weeks of Oscar data from consistent settings, it may become much more obvious where you want to go in terms of both possible setting changes as well as other things that may need to be changed in your life to get the quality of sleep you want to have.

[Pugsy]

RobySue makes some very valid points. I have nothing to add to them.

[forJO]

Removed

[Pugsy]

Curious what you would recommend I focus on trying for this situation. I can post OSCAR results if needed but wanted to get the question out there first.

Please start a new topic/thread of your own and don't go posting your stuff in someone else's thread. It's considered bad form for one thing, rude for another and can lead to confusion in this thread.
And yes...post your own OSCAR detailed report in YOUR new topic/thread.

Thank you.