Interpreting Encore Pro Data

[Restless1]

Hi,

I am new to all this, and I am confused. Because I did not sleep when I went to be titrated, I have a Respironics Auto PAP with C-Flex. The results of my first polysomnography report were: 18 obstructive apneas, 6 central apneas, 84 hypopneas for an AHI of 25.3. I only slept 256 minutes (4.3 hours).

My first week with the APAP did not go well as I usually had it on for less than 4 hours each night. I received a smaller mask on Monday (DMEgave me the wrong size) these are my results. When the pressure gets up to 11 or 12, my mask leaks.

8/6/07 5.8 hrs, 90% pressure 12, avg pressure 8.2, AHI 20.0, time in apnea 16.7 min., NR 0.5

8/7/07 7.7 hrs, 90% pressure 11, avg pressure 6.6, AHI 16.0, time in apnea 16.0 min., NR 0.3

8/8/07 7.5 hrs, 90% pressure 12, avg pressure 8.7, AHI 16.0, time in apnea 14.2 min., NR 0.3


Last night’s results were:

Pressure 4; 67.5 minutes; 14.9% of night; AHI 9.8
Pressure 5; 23.5 minutes; 5.2% of night; AHI 35.7
Pressure 6; 53.5 minutes; 11.8% of night; AHI 21.3
Pressure 7; 14.5 minutes; 3.2% of night; AHI 49.7
Pressure 8; 20.5 minutes; 4.5% of night; AHI 38.0
Pressure 9; 79.0 minutes; 17.5% of night; AHI 6.1
Pressure 10; 44.0 minutes; 9.7% of night; AHI 20.5
Pressure 11; 34.5 minutes; 7.6%of night; AHI 17.4
Pressure 12; 84.5 minutes; 18.7% of night; AHI 7.1
Pressure 13; 24.5 minutes; 5.4% of night; AHI 19.6
Pressure 14; 5.5 minutes; 1.2% of night; AHI 32.7
Pressure 15; 1.0 minutes; 0.2% of night; AHI 120.0


I am beginning to wonder why I am even using this machine because my AHI is still rather high. I am assuming that because my NR is below 1, most of the OA and H were resolved, but shouldn’t my AHI be below 5?

Could someone explain this to me and what would you recommend. I have not seen a doctor. They were supposed to call me to schedule an appointment, but they haven’t. I was only told that they were ordering an auto CPAP to see if I could be desensitized to it.

I wish there were a book that explained all this. I’ve read many threads in the forum, but I am still confused.

Thanks for all your help.

[Guest]

Restless--you should consult a doctor about your results. This is a serious breathing disorder you are treating, not something you should leave up to the opinion and conjecture of strangers (despite how well-versed they think they are)

[Goofproof]

Especially, if they have to log in as a "Guest" Restless1, you need to join and fill in your profile, so we can see what you are using and how it's set up.

"Guest" would prefer you only have the good useless advice like you have received from the medical profession so far, the same kind he would like for all his customers. Jim

"Would you like Fries with that?

[Goofproof]

Sorry, Restless1, I was in the write mode and didn't see you had your profile filled in.

It looks like your machine is set for a wide pressure range, that's bad.

Usually a 2 cm under and 2 cm over your CPAP pressure works best. You are using a Nasal Mask, in Encore Pro page 4 (Dailies) what is your AVG leak rate, and your Large Leak rate minutes.

Leak rates have to be controled for the data and treatment to be useful. With a nasal interface, mouthleaking can accure causing you to lose your treatment, the leak rate will give us a clue. Jim

[Guest]

Those "NR" or Non-Responsive Apnea/Hypopnea events are a concern. From the looks of your titration you have the wrong machine.

Your AHI (sum of Apnea/Hypopnea per hour) is all over the place, the data you are looking at can be "skewed" either from excessive mask leak or the machine is totally misreading you.

Those NR's can mean:

1. Apnea that doesn't clear with any pressure, such as from effects of GERD, so if you have GERD you want to also treat that with elevating the head of your bed and/or taking Prilosec (or apple cider vinegar).

2. Those "NR"'s can also be CENTRAL APNEA. Then that would explain your data, meaning that probably more than half of those Apnea/Hypopnea logged are actually central apnea NOT obstructive.

So if you haven't had any past history of heart burn or GERD, then I would suspect those apnea seen are central apnea. Check your diagnostic PSG, it should indicate "CA" or "MA" events, if it does you WILL NEED to "limit" any pressure response from your machine.

Just looking at your data, 9.0cm appears to be the best pressure for you. That pressure is also "in-line" if you are at risk of Central Apnea (CA). Your best bet is to switch your machine to CPAP mode at 9.0 cm pressure. It will still record events, just not respond to them.

I don't know if you would do better on a A-Flex machine (I seem too). IF you have Complex Sleep Disordered Breathing (CSDB) then you may need an entirely different machine in a Adapt SV. People with CSDB have a combination of obstructive sleep apnea and central sleep apnea, then it can be combined with a "mix" of obstructive/central apnea or Mixed apnea, sometimes you can blow through it or avoid it depending on the machine but if not you need to be retitrated on a Adapt SV machine.

At this point, your best bet is using machine at 9.0 cm on CPAP "mode". The changing pressure of your auto can make CSDB worse, reason they call it complex.
You need to see your sleep doc and ask about what was seen on your PSG and titration.

[Wulfman...]

Restless--you should consult a doctor about your results. This is a serious breathing disorder you are treating, not something you should leave up to the opinion and conjecture of strangers (despite how well-versed they think they are)

I'm actually going to agree with this guy for a change.

The fact that you didn't get to sleep during your titration, plus the fact that you showed some centrals on your initial sleep study have forced them to give you an Auto to see if there's a pressure that will work for you.

It looks like, from your stats (from last night), that 9 and 12 are better than all the rest. Could be that you're getting pressure induced centrals at higher pressures and the lower pressures aren't getting the job done. (Plus a multitude of other factors including other health issues)

Depending on how long you've been using your machine, your initial numbers when starting therapy CAN be somewhat higher than after things get settled in.

Yep.....they need to know what your stats are. Maybe they can zero in on a pressure.

Good luck,

Den

[Snoredog~]

PS those "NR"'s should ALWAYS be 0.0 (zero), you should never see anything logged in NR, if you do you have problems.

NR is Non-Responsive Apnea/Hypopnea. Meaning the machine tried to eliminate what it seen as an obstructive apnea and it did not clear those events after 3 attempts, when that happens it logs a NR event.

So unless you know for sure you have Paradoxical Vocal Cord Dysfunction from the effects of untreated GERD, you either need to see a GI Specialist or you have Central Apnea and on the wrong machine.

Based upon the looks of your data, you have a form of Central Apnea, no GERD or PVCD is that stubborn.

[Restless1]

Goofproof, thank you for your response. My machine is set at 4-20 as prescribed by the doctor.

I had no large leaks (0.0 minutes) any of the three nights.

My average leaks this week were:
8/6/07 36.6
8/7/07 31.74
8/8/07 37.29

What should the leak rate be under? I really didn't feel any leaks until the pressure got up to 12 and then I woke up.

From the first week where I only used the machine for 33 hrs 43 min for 7 days, my REMstar Auto statistics were: (I used a ComfortGel that was too large for the first 4 days and then a Mirage Swift for 3 days, but my nose was sore and I had trouble getting it adjusted for leaks)
Auto-CPAP mean pressure 5.5 cm
Auto-CPAP peak average pressure 7.3 cm
Average device presue <=90% of time 8.0 cm
average time in apnea per day - 3.6 min
average time in large leak per day 0 min
average AHI 10.0

For the first week, I had 1 NR for an average of 0.1 (33 hrs 43 min of use) (That was when I couldn't get the Mirage Swift adjusted for no leaks.) No NRs the other days, although I didn't use the machine long.
average max leak 97.0
average 90% leak 39.8
average leak 29.6
average large leak 0 minutes

Monday, I got a smaller ComfortGel mask.
On Monday, I had 3 NR, AHI 20.1, no large leak, avg leak 36.6
Tuesday, 2 NR, AHI 16.1, no large leak, avg leak 31.74
Wednesday, 2 NR, AHI 16.6, no large leak, avg leak 37.29

I suppose there isn't enough data yet to go to the doctor. I thought I would wait for another week of data before I go see him.

Guest, I did ask my DME about an A-flex, but she said they didn't have any; I was getting a C-flex. I really didn't have a choice in the matter.

I do not have GERD. I did not get a copy of the diagnostic PSG only a typed report that shows I had 6 central apneas. No one seems to want to give me anything. Even my DME said she couldn't show me the titration report or prescription, although I saw later in the Bill of Rights I was entitled to it. So it really makes me angry and frustrated that no one will show me anything and my doctor's office doesn't call.

I don't know if this makes a difference, but I have been taking 0.5 mg of Ativan (tranquilizer) before bedtime since I got the machine. When I had my first sleep test, I had to take 1 mg of Ativan in order to sleep even though I had not taken it for 3 months. I shall try going without it Friday night when I don't have to get up for work the next day.

Guest (also posted as Snoredog), you said "...or the machine is totally misreading you." I was wondering if that was possible, because sometimes I hold my breath. I am used to practicing inhale for a count of 5, hold for 2, exhale for 5.

Thank you everyone.

[Guest]

Goofproof, thank you for your response. My machine is set at 4-20 as prescribed by the doctor.

I had no large leaks (0.0 minutes) any of the three nights.

My average leaks this week were:
8/6/07 36.6
8/7/07 31.74
8/8/07 37.29

What should the leak rate be under? I really didn't feel any leaks until the pressure got up to 12 and then I woke up.

From the first week where I only used the machine for 33 hrs 43 min for 7 days, my REMstar Auto statistics were: (I used a ComfortGel that was too large for the first 4 days and then a Mirage Swift for 3 days, but my nose was sore and I had trouble getting it adjusted for leaks)
Auto-CPAP mean pressure 5.5 cm
Auto-CPAP peak average pressure 7.3 cm
Average device presue <=90% of time 8.0 cm
average time in apnea per day - 3.6 min
average time in large leak per day 0 min
average AHI 10.0

For the first week, I had 1 NR for an average of 0.1 (33 hrs 43 min of use) (That was when I couldn't get the Mirage Swift adjusted for no leaks.) No NRs the other days, although I didn't use the machine long.
average max leak 97.0
average 90% leak 39.8
average leak 29.6
average large leak 0 minutes

Monday, I got a smaller ComfortGel mask.
On Monday, I had 3 NR, AHI 20.1, no large leak, avg leak 36.6
Tuesday, 2 NR, AHI 16.1, no large leak, avg leak 31.74
Wednesday, 2 NR, AHI 16.6, no large leak, avg leak 37.29

I suppose there isn't enough data yet to go to the doctor. I thought I would wait for another week of data before I go see him.

Guest, I did ask my DME about an A-flex, but she said they didn't have any; I was getting a C-flex. I really didn't have a choice in the matter.

I do not have GERD. I did not get a copy of the diagnostic PSG only a typed report that shows I had 6 central apneas. No one seems to want to give me anything. Even my DME said she couldn't show me the titration report or prescription, although I saw later in the Bill of Rights I was entitled to it. So it really makes me angry and frustrated that no one will show me anything and my doctor's office doesn't call.

I don't know if this makes a difference, but I have been taking 0.5 mg of Ativan (tranquilizer) before bedtime since I got the machine. When I had my first sleep test, I had to take 1 mg of Ativan in order to sleep even though I had not taken it for 3 months. I shall try going without it Friday night when I don't have to get up for work the next day.

Guest (also posted as Snoredog), you said "...or the machine is totally misreading you." I was wondering if that was possible, because sometimes I hold my breath. I am used to practicing inhale for a count of 5, hold for 2, exhale for 5.

Thank you everyone.

On the days where your leak was over 75 L/m you can throw out that data as it is skewed. The machine will STOP responding with leak over 75 Liters a minute and start reducing pressure to eliminate the leak.

Note: you have a LEGAL right to your medical test results, if you are not getting that request it in writing with a letter and if you still don't get it, threaten legal action. Your doctor may dump you after that but I would see that as a good thing.

If they don't share your test results with you, it usually means they are afraid of being sued for malpractice should they miss a diagnosis. If you don't have your test results it is pretty hard for you to say hey doc you missed these PLM's on my report.

A doctor that is good won't have any problems giving you a copy of your results. They say here is what I think and you are free to obtain a second opinion if you like.

You pay for insurance, you pay for those tests, you have every legal right to take the test results on tests already performed to another doctor for a second or even a 3rd opinion without having to have any test redone.

In your case, your AHI is INCREASING with pressure. You do worse at higher pressure than lower. There are a few "valleys" in your pressure where AHI is lower, that could be your so called sweet spot where fewer events will be seen, from your data, that is at 9.0 cm and 12.0 cm. Changing pressure before and after those pressures are then double-digit, meaning your condition only gets worse with changing pressure of the autopap.

To avoid events caused by changing pressure, you need a constant steady pressure of CPAP and even that may produce erratic results at times. At this point and looking at your data, you do better at lower pressure than higher pressure, 9.0 had the lowest AHI of 6.1. While that AHI=6.1 was not ideal and only 17.5% of the night and 6.1 is still higher than what we shoot for, with a risk/history of central apnea noted on your PSG, most if not all of that 6.1 residual AHI is possibly from central apnea being mis-scored by the machine.

The reason is Central apnea generally doesn't respond well to changing or increasing pressure, could be why your AHI goes to double-digit values.

While there is a machine for that called the Adapt SV, it works by manipulation of the respiratory drive chemoreceptors to stabilize breathing and avoidance tactics. Once you stabilize your breathing those CA's should go away on their own.

Until you can get in to see your doctor and drill them on your PSG results, I would set your pressure no higher than 9.0 cm. Any pressure over 8.0cm is going to clear more than 70% of the events seen.

Your current machine cannot do a very good job at avoiding those centrals, it sees them as obstructive, it responds with increased pressure of which we know only makes CA's increase in frequency.

So the next best thing to a AdaptSV is constant solid pressure from CPAP. It may also help to lower the AHI seen by using a different mask interface that retains more CO2. Now don't tell me you are using a swift or a nasalaire, because those interfaces may make your condition worse, the ComfortGel would be much better fit in my opinion.

There was one night in your latest post using 8.0cm had a lower score, my guess is your ideal pressure is under 9.0cm probably in the 8.5 to 9.0 cm range.

If your leak rate is in the 28-32 L/m range using a ComfortGel, based upon your pressure I think that is pretty good and not much of a problem.

But you don't want to see any "max" leak above 75L/m because that means the machine had to take a different action because of the leak, the autopap algorithm will stop functioning above that leak rate, machine will drop pressure by 2cm and continue dropping pressure until leak subsides.

[Goofproof]

The Comfort Gel mask works pretty good up to 36 LPM, if you can stay under that good 32 would be preffered.

As far as being set 4 cm to 20 cm, that in it's self is reason to fail. The machine won't respond to events in time or correctly, the person who set you up with that pressure is a fool, plain and simple, or at least simple. I wasn't aware of your other problems, but no wonder it's not working. Jim

[SAG the Guest Again]

The problem with picking 9 cmH2O (or 12 cmH2O, for that matter) is that if CSDB is underfoot, and those pressures were used doing REM, although the AHI in those areas is lower than the other pressures, a CSDB patient may not need any pressure whatsoever during REM, so those values could be misleading.

A burst of SWS during those periods could also do it.

However, everything you mention points to insomnia as a (the?) major hurdle.

Because I did not sleep when I went to be titrated

I only slept 256 minutes (during diagnostic)

My first week with the APAP did not go well as I usually had it on for less than 4 hours each night.

I have been taking 0.5 mg of Ativan (tranquilizer) before bedtime since I got the machine.

When I had my first sleep test, I had to take 1 mg of Ativan in order to sleep even though I had not taken it for 3 months.

Generally, running an APAP at 4-20 cmH2O isn't the worst thing in the world (since there was no data during sleep in the CPAP titration, you're really just gathering info). A few days of data and seeing how it behaves, even if it tops out, can be quite helpful.

However, if

I was only told that they were ordering an auto CPAP to see if I could be desensitized to it.

that does not entail using a 4/20 range, that entails using the lowest, most comfortable pressure (like 5 cmH2O) to simply get used to the therapy.

If your sleep efficiency is still only 50%, that should be the primary area of attack.

Sarcoid, eh? Is that a "had" sarcoid, or a "got" sarcoid?
SAG

[Restless1]

I had sarcoidosis in 1998. I think it was caused by herbal remedies. The last time I saw my pulmonologist for it was in 2002, at which time he said he didn't need to see me any more. My breathing was fine, but there were still lesions on my lungs. I don't think it has bothered me. But for maybe the last year I have been out of breath walking up 22 steps, and I don't know why.

Last night I set my auto-pap to cpap at 8.5 and ramp. (THANKS TO THIS FORUM I FOUND THE DIRECTIONS ON HOW TO CHANGE IT.) I woke up in 2 hours with a very dry throat so I changed it back to auto-pap.

For the 2 hours at cpap 8.5, I had:
NR - none
OA - 2.6
H - 1.0
AHI: 3.6
no large leaks
avg leak 44.64

After I changed it to auto-pap 4 to 8.5, I had:
NR - none
OA - 2.7
H - 6.5
AHI - 9.2
no large leaks
avg leak 30.41

Average AHI for the night was 7.4.

That was definitely better than 16 - 20 AHI. THANKS GUYS FOR ALL YOUR ADICE. I really appreciate it.

I'll try it at 7 c-pap tonight all night.

I'm still trying to get a doctor's appointment. I was told that even though I had seen the pulmonologist in 2002, I am considered a new patient and I need a referral from my primary care doctor (so he knows who to send the letter to about me). This is not the doctor that signed my sleep test report. I have given up on getting an appointment with him.[/u][/b]

[Wulfman...]

If you woke up with a dry throat, it's a good bet that your were mouth-leaking (I think your leak rate might indicate that, too). Taping your mouth shut, using Polident adhesive strips to seal the lips or using a full face mask will help resolve that.

I'm not sure why you want to drop your pressure that low......but, it's YOUR therapy. (I would suggest fixing the mouth leak first and leaving the pressure at around 8.5 or 9)

Good luck.

Den