Question on apap

[MRH]

No beard anymore This will be the first winter since 1981 without one. still have a moustache though. I think that the leaks are from the chin area, in the mornings I have the lines from the nose down to about my mouth corners. I do know that I relax my jaw when I am asleep. I was playing with straight cpap before I got this auto and had went up to 12cm but it didn't really change much from the 11 that I started out with. I was hoping that switching to the apap it would be able to show me the right pressure, because I would have flat lines that (better then this one but still not perfect) still showed apneas. I thought I was doing good with the avg leaks, but maybe I was wrong and need to work more on leaks!

Thanks a bunch,

Mark

[Wulfman]

Mark,

If you'll notice on your chart, the places where your leak line is flat.....is also absent of almost all events, too. And, consequently when your leak line goes crazy, you start having apnea events, big time.

Like all masks and individuals, we all have the ones that work best for each of us. The one you're using is no different. I've read lots of "leakage" stories about the HC431. It may be time to try to get a different mask.

My two favorites are the Ultra Mirage FF and the Quattro......properly sized and adjusted, of course.

Good luck.

Den

[DreamStalker]

I suspect you are starting out sleeping on your side and then you roll over onto your back and the leaks go nuts. On the other hand it may be exactly the opposite and you start on your back then go onto your side.

With full face masks, there is more facial real estate to keep sealed and when you shift from side to back the contours of your face change and seal is broken. At your relatively high pressure, the broken seals get out of control and the machine tries to compensate making the leaks worse.

Try and make sure that the lower strap is adjusted over the back of your skull and off the back of your neck if you can ... that will reduce the variability in strap tension as you move your head about at night.

It is probably not an easy thing to do but you may also want to try sleeping on your side when ever you can remember.

[MRH]

Den thanks for all the help maybe I need to try another mask then. The 431 has been comfortable for me and it was way better on the leaks then the Comfortfull I had tried before. Maybe I should put the pressure back to the 9 to 13 range for longer and try to get another mask. I have even been shaving at the least every other night.

Mark

[MRH]

Dreamstalker,

I think you are right on the leaks too, I always start on my back and end up on my sides, wake up then roll on my back again. Another bad night last night too. I did have better nights on the straight before the auto came on the seen maybe I should go back to straight pressure.

Thanks,
Mark

[Wulfman]

With straight pressure, you're also narrowing the list of "usual suspects" when trying to figure things out.

With a range of pressures, you have to have your mask tight enough for the highest pressure you're going to reach.....and that can be uncomfortable at the lower pressures.

By the way, the only other full face mask I've tried is the Comfortfull 2 and intensely disliked it for the 3 nights I managed to be able to wear it.

And, along the lines of what DreamStalker was talking about.....sleeping position......sleeping on one's back is worse for apnea-type events. If you're on your back at those times that are showing on your chart when you're having the clustered events, you'd better try to stay on your side.


Den

[Slinky]

I am not that familiar w/the Respironics software. And it is only ONE night's data but ....

In the bottom chart, the Daily Events Per Hour chart it looks like 15-16 cms of pressure gave the best results.

[Snoredog]

My Opinion:

seen EncorePro reports like that a hundred times.

Hate to break the news to you, but they missed your titration. You and Rooster have the same dysfunctional sleep lab?

See all those "NR"s at the top of that chart? You should NOT have any of those at all. Then look at your OA pattern, see the clusters and then clear breaks?

Are those clusters corresponding to periods of REM? They could, that would be where your ole tongue would flop back down in the hole also.

Maybe you, Rooster, Curt46 and several others should compare your EncorePro reports for that distinct OA pattern. Maybe you are like Rooster and have a tongue that once it gets lodged into that hole at the back of your throat it takes 100PSI and a Ingersol Rand jack hammer compressor on a trailer to blow it back out of the hole (don't even tell me you are using that stupid Hybrid mask).

You might try sleeping on your side and comparing numbers.

AHI=15 at 17 cm pressure and STILL bumping up on the Max set limit? you might as well open the thing all the way up but my guess is the situation won't improve any from what you see above. If you really want a lower AHI score here is what you do, you stabilize breathing, yours is all over the place, the number of events seen will go down without the machine.

And I ain't buying any stubborn GERD theories here either. If you really want to lower your AHI and get better sleep, ignore what you read and set your machine to these values THEN compare those nights sleep to the above. You have to prove it to your self before you make any progress.

-Therapy Mode=AFLEX (CFLEX/AFLEX)

-Auto:Max=10 (default=20.0cm)*

-Auto:Min=7.0-8.0 (default=4.0cm, Note: AFLEX doesn't work below 6.5 cm)

-FLEX Setting=1 (options are off, 1, 2 or 3)

-AutoRamp Time=30 (options are 05 to 45 min)

-AutoRamp Pressure=6.5cm (4cm->AutoMin)

-Mask Alert Feature=ON (On/Off)

-Auto Off Feature=Off (On/off)

-Split Night Time = Off (off, 120, 180, 240)

-Show AHI/Leak Feature=ON (On/Off)

Set it to the above, sleep with it 1 night and compare to your other report above.
Note: You may even have to lower Auto:Max=10 to 9.0. Sure it may want to bump up to the Max at times, don't worry about it. It is important to keep the Min at 8.0 or below.

Having NO CA's listed on your PSG wouldn't surprise me, we see that all the time, usually when they have a follow up study they magically and suddenly find them.

It is kind of like receiving a HDTV signal, either you get it or you don't, if you get it you have a crystal clear picture, if not no picture.

NR=NRAH or Non-Responsive Apnea or Hypopnea. So it is an event that after 3 tries does NOT respond to pressure. Now understand for it to throw up that NR flag, it has to see "3 events in a row" to qualify as NR. If it only sees 2 of the needed 3, it throws up a "OA" (see those clusters, those are mainly made up of events that eventually become a NR, that is why there are so many found in the clusters).

You can try setting your Max=20 and maybe it might blow through it, but I doubt it, machine will most likely chase that pressure setting also, you need to settle down your sleep and/or sleep on your side to make it easier for the machine to blow the tongue back out of the hole.

Try it 1 night and compare, try sleeping on your side even if you can only do that the first part of the night, at least you will be able to compare it to the latter half.
Try sleeping with a backpack on loaded with a 12 pack of beer, that will keep you from sleeping on your back.

[MRH]

Snoredog,

So you think I should set the min at 7 and the max at 10 correct? I will give it a try. The sleep study only went up to 11 and that is where it showed no events so maybe I should set the max at 11? Also my mask is 3 months old, do I need a new seal? It seems it isn't as firm fitting as it used to be. I do sleep on my side during the night... No problem with that, I have been sleeping on my back since starting this sleep apnea thing to try to keep from getting leaks in the mask. And ow do I stabilize my breathing?

Thanks for the advice,
Mark

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CPAPopedia Keywords Contained In This Post (Click For Definition): seal

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CPAPopedia Keywords Contained In This Post (Click For Definition): seal

[echo]

Having NO CA's listed on your PSG wouldn't surprise me, we see that all the time, usually when they have a follow up study they magically and suddenly find them.

Bingo! That happened to me! Didn't notice any central's on the PSG until they did the titration, then a couple popped up, and then magically when they went back to look on the previous PSG they found a few centrals.

Anyhoo that's my 2 cents. Not sure if that helps this discussion any sorry I didn't follow the whole thread.
Good luck finding what works for you!

[Snoredog]

Snoredog,

So you think I should set the min at 7 and the max at 10 correct? I will give it a try. The sleep study only went up to 11 and that is where it showed no events so maybe I should set the max at 11? Also my mask is 3 months old, do I need a new seal? It seems it isn't as firm fitting as it used to be. I do sleep on my side during the night... No problem with that, I have been sleeping on my back since starting this sleep apnea thing to try to keep from getting leaks in the mask. And ow do I stabilize my breathing?

Thanks for the advice,
Mark

That is correct, however since you are on A-Flex, getting down to 7.0 on the minimum side may starve you for air (we are all different when it comes to that particular aspect). 7.0 is okay for me while on my 420e but too low on my A-Flex, so if you start feeling stuffy at 7.0 bump it to 8.0. If No events were seen on your titration PSG at 11 cm, then set the Auto:Max=11, but if reports show those same patterns of OA appearing, then you may need to drop it to 9.0.

The side sleeping test is important also, it tells you where the obstruction problem is, I wouldn't worry about the leaking so much, just ignore the data when leak goes over 75L/m. Keep any overall leak under 50 you'll be fine.

You are also using a Full Face mask, keep in mind if your obstruction is typical, it will be the tongue relaxing and falling into the back of the throat on inhale. If that is the case, sleeping on your side should lessen that effect and make it easier for the machine to splint the tongue out of the way it doesn't have to fight against gravity so much.

Again, you are comparing a residual AHI=15 @17cm pressure seen to a AHI=xx@11cm pressure. IF sleeping on your side also reduces the number of obstructions seen, then you have already helped the machine in obtaining a lower score. The fewer events you have the better you will feel.

If you have any nasal congestion it would be to your benefit to address that as well, that includes removal of any nose hair with a Panasonic like nose hair trimmer.

[MRH]

Here is a chart from last night better for sure. I set it close to what Snoredog recomended. I also slept on my side, at least I think I did most of the night and the leaks were better then I figured they would be.

Mark

[rested gal]

And I ain't buying any stubborn GERD theories here either.]

heheh

Well, I am.

Looks an awful lot like what was happening with loonlvr a long time ago:

Mar 10, 2005 subject: What is the REMStar Auto really doing? Derek, -SWS, Wader, and a very intelligent "Fascinated" Guest discuss loonlvr's posted charts. Extremely interesting 5 page topic.

Mar 18, 2005 subject: What's REMStar Auto Really Doing? - new thread Derek posts more of loonlvr's charts.

Nov 05, 2005 subject: SUCCESS AT LAST-GERD,420E, PRILOSEC AND BENADRYL -SWS's thoughts on loonlvr's massive clusters of events and loonlvr's followup post.

[Snoredog]

Here is a chart from last night better for sure. I set it close to what Snoredog recomended. I also slept on my side, at least I think I did most of the night and the leaks were better then I figured they would be.

Mark

Well that didn't really tell us anything, but your AHI got better, you only had 1 NR for the whole night, now an ENT would call that successful, but not here. Your sleep is still a major train wreck, you need to find out why so you can fix it.

I would try:

Auto:Max=20 cm
Auto:Min=8.0 cm
Flex=2 (increase this by 1)

Now the above settings is to determine if the events are obstructive, 20 cm pressure should blow your tongue out of the hole, if it doesn't you need to try a "nasal" mask and/or use a vertical chin strap or tape, ACE bandage would also work for one night. You may need the therapy pressure to be delivered via nasal as opposed to oral, it is a matter of physics, much easier for that air pressure to push that tongue away from the back of the throat when it is coming in from the nares.

On another night you may want to put the machine into CPAP mode and set it to 9.0 cm pressure. 9.0 is an important value (don't get close or deviate), it is to rule out those NR's as being possibly central, if you are not going to use 9.0 in cpap mode then don't even bother with doing this because you blow past the algorithm triggers using a higher setting. CPAP mode avoids those triggers altogether. Then CPAP mode will give you constant pressure to rule out the auto's changing pressure of auto mode as contributing to those NR's events (that is if they are central based). Your risk of having a central apnea at or below 9.0 cm pressure is very low (as compared to 10cm or even 11) and that is what we are trying to rule out here by trailing those CPAP setting at 9.0, if you have fewer SDB events at that lower pressure then it means you don't tolerate higher/changing cpap pressure(s) well.

You already tried CPAP mode at 11cm same as the lab found right? How did that report compare to the above? You can't really use that here because you are again above 9.0 cm pressure.

If your pressure requirement continues to climb and you are still having all those residual events, you may need to see an ENT for an exam.

If you cannot breathe through your nose this therapy will not work for you.
That includes nose hairs, you have to get those suckers out, get one of those nose hair trimmers its gone in a flash.

People with greater than 80% blocked nasal passages half the time don't even know it because it happens so gradual over years they simply get used to it and never realize they cannot breathe through their nose.

If you go to a ENT for an exam, they will scope into your nose and check for any obstructions and tell you within a few minutes if you have a problem. It is a quick and painless exam, at least when you leave there you know where you are at.

This actually should be all part of Sleep medicine in diagnosing OSA before recommending treatment. How (as a Sleep Specialist) can you recommend CPAP therapy to a patient if they cannot breathe through their nose?

Fact is you can't, but they do it anyway, most of those patients fail treatment as a result.

If they (sleep specialists) were doing their job they would have a looksee themselves into your nose to make sure you can breathe through your nose first before scripting CPAP therapy.

But the norm is for them to let you struggle along with it for months or even a year switching masks, performing additional titration studies and getting basically no where. Hell find out if the guy can even breathe through his nose first will ya.

[ozij]

What we know:

PSG titration at 11 - apparently no events there.

Remstar Pro, straight pressure AHI high, leak problem on many kinds of masks. In June RG suggested you check GERD as an explanation. Den notices leaks and events go hand in hand.

Remstar Auto night of nov. 5 to 6, pressure :10-17 hits the 17 a lot, OA index 13.8, HI 1.4 vs. 6.9
Seems to me that on that chart, events batches start when the leaks start.

Remstar Auto night of nov 7 to 8, pressure 7 - 12: hits the 12 a lot. OA index is down to 4.8 (!) H is at 3. but the VS, 35.6.

Events seem to start with leaks (see hours 3.5, 4.5 6.5)

My conclusion: 7 is too low. 10 may even be too high.

Basing it on 2 nights is not something feel too happy about, however, I agree with snoredog's recommendations, but would try it in a different order:

I would try Straight PAP at 9.0 before checking the up to 20 option.

My reasoning is that if 9.0 will keep events from starting out, (less snores, and hypopneas) then you're better off. It will also be better as far as leaks are concerned.


O.

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, AHI, auto