Strange Results - Need Help

[Tallen234]

Ok, I am now over one week into this and am more confused that ever. Here are my results:

Day 1 (autoset 7-14 by DME) Pressure - 8.0, Leak .36 AHI 14.5 AI .7 HI 13.8
Day 2 (no data, forgot to check before noon)
Day 3 (7-14) 8.8 .34 20.8 4.1 16.7
Day 4 (8-14) 9.6 .46 31.9 6.9 25.0
Day 5 (8-14) 9.4 .06 (really tried to eliminte leaks, causing sore on nose!) 30.0! 7 23.0
Day 6 (9.5 -15) 10.2 .08 22.3 3.6 18.7
Day 7 (10.4 - 16) 10.8 .24 20.7 3.0 17.7

After Day 4, I finally received a copy of my titration study. I know my results were pretty spotty as I barely slept during the study, but they found some interesting results. The titration study said that they recommend "CPAP pressures of 14 to 15". During the study, they never got the pressure up that high. I am a bit worried that they are making some of this up, as I didn't sleep very much during the study. At best it was a flawed study.

So, given this, I am a bit surprised they set the autoset at 7-14. I am still tired in the morning, wake up about 2-3 times a night and am developing a pressure sore on the bridge of my nose.

I am almost tempted to put the autoset on 14 to 15 (like the titration study recommended, to see what happens)

Any insight would be greatly appreciated!

[jnk]

If you are having mask troubles, that needs to be worked out before you even THINK about judging the results of your therapy or messing with pressures. If the mask isn't fitting and you are getting leaks, you can either start rigging up some tricks to make that mask work or start shopping for a new mask. But until you can consistently get low leak, none of the other numbers mean much and the auto can't begin to do its job.

The above opinion is, I believe, in harmony with the thinking of most in this forum. What I am about to say is not.

My personal opinion is that if you use a particular brand's auto machine, you should use that brand of mask. Autos are slightly different beasts from the other machines. They are relatively new technology, and they are designed to REACT to what they sense. With the ResMed, if you use a ResMed mask then you can tell the machine what mask you are using and that makes the reported leak easier to read. But the main thing is that you want the machine to be able to figure out what it is sensing so that it can figure out how to react.

Now back to mainstream opinion, as I understand it:

The 7 to 14 range is not unreasonable to start with, no matter what your sleep study did or did not discern. At least they didn't put it at 4 to 20. So I would leave that alone for now and get the mask thing figured out first. Then your reported numbers will start to mean something and you can go from there with the help of some of the data gurus in this forum.

Note to rest of forum: Feel free to slice and dice the above suggestions!

[ozij]

My personal opinion is that if you use a particular brand's auto machine, you should use that brand of mask. Autos are slightly different beasts from the other machines.

Slicing and dicing:

Masks have to fit faces.
Some mask manufacturers do not even make automatic machines, and yet their masks are execellent.
It is crucial to have a mask that fits your face.
The human face, and human sleep habit are much more sensitive than autopaps. When searching for a mask, don't limit yourself to the brand of your machine.

We all know how careful machine makers are to cover themselves by all kinds of warning statements. None has yet made the following statement:
"If the masks we make do not fit your face or cause you to develop sores DO NOT USE OUR MASKS AND DO NOT USE OUR AUTOMATIC MACHINES". And if they haven't found it necessary to make that announcement, them I do not thik their statements that they only tested their owm masks on their machines means much.

When we use an auto for nightly therapy, we don't mind if with our specific mask it need 0.5 cms pressure more (or less) than with another mask. Those between mask discrepancies become an issue only when an Rx for fixed pressure on another machine is based on the auto's titration.

You will find the rare mask that will make problems for auto therapy - but all in all, the priority should be for finding a comfortable mask, regardless of its brand.
O.

[Paul56]

My personal opinion is that if you use a particular brand's auto machine, you should use that brand of mask.

That is certainly in harmony with my feelings about it as well. Hopefully one can obtain a mask from that vendor that fits.

[jnk]

". . . None has yet made the following statement:
'If the masks we make do not fit your face or cause you to develop sores DO NOT USE OUR MASKS AND DO NOT USE OUR AUTOMATIC MACHINES' . . ."

ozij,

Thanks for the slice and dice! I'm flattered! And I AM truly glad you did. For the record, I trust your judgment above my own on such matters. And I didn't mean to cloud the issue that the most important thing is getting the right mask, regardless of manufacturer.

ResMed has, though, come about as close as any company has to saying 'be careful using our masks on other companies' machines':

"Can the ResMed mask family be used with just about any other brand of CPAP?
It should be fine, but if you're using a non-ResMed APAP or Bi-level device, you may want to check with the manufacturer."

http://www.resmed.com/en-us/products/se ... oducts#Q19

But my opinion was based almost solely on the ResMed statement about their own machines, a statement meant to promote the selling of their own products, I'm sure:

"Why do AutoSet devices work with only some masks? Why not all masks?

". . . all masks have different physical characteristics and an AutoSet device needs to know the specific characteristics of a mask for best performance. AutoSet devices respond to conditions like leak, snore, and inspiratory flow limitation. To properly treat a person with obstructive sleep apnea (OSA), an AutoSet device needs to know exactly how much of the conditions it detects come from the mask. All masks have some degree of leak to ensure users get fresh air. All masks also have some degree of resistance by virtue of their materials, contours, and leak. So using a mask that is "unknown" to the AutoSet device won't let it do its job properly."

http://www.resmed.com/en-us/patients/tr ... ucts#masks

The clinician's manual for my machine says this:

"In VAuto mode, only ResMed masks are compatible for use with the
VPAP Auto."

VAuto mode is the auto-bilevel mode. So the statement implies to me that it must not be important in plain bilevel mode or straight cpap mode.

I'm sure ResMed is mostly just covering their own butts. But for worry-warts like me, those statements tend to eat into my brain and make me want to drink the kool-aid, I guess.

Anyway, my suggestion would be that any auto users in the market for a new mask at least consider masks from the manufacturer of their machine, especially if the machine tends to suffer from runaway-pressure disease.

[Tallen234]

Wow. Thanks for the advice everyone.

If you look closely at my results, I have (hopefully) reduced the leak problems (probably at the expense of my nose!), but the last three nights, my leak rate was .06, .08 and .24. My AHI was 30, 22.3 and 20.7. So, even with tackling the leaks, my AHI is still out of control. However, with increasing the initial pressure from 8 to 9.4 to 10.4 my AHI was going in the right direction. So, correct me if I a wrong, this seems to suggest that I should increase the pressure again, since there is a positive correlation between the increase in pressure and the decrease in my AHI. I know the sample size is pretty small...but I want to get his under control as I am feeling worse than even before I started the therapy.

After reading my sleep study, which is very complicated, I increased the pressure over the past three days to hopefully mirror the range recommended by the titration study - 14 to 15.


My titration study states:

The patient was initially started on CPAP at 5 cm of water pressure and was gradually titrated up to 11cm. Initially at 11cm the patient did well, though after nearly an hour of consolidated sleep the patient had an awakening. This was followed by reappearance of central apneas and hyopneas, because of which CPAP pressures were gradually titrated up to 13 cm. At the highest pressure achieved initially, the patient again did not have any breathing events, though toward the tail end of the study scattered hyponeas and Respiratory Effort-Related Arousals as well as central apneas were seen. The central apneas would present after the patient had arousals. Thus it appears that the patient was slightly under-titrated. He did not have much in the form of air leak.....

Recommendations

Based on the findings of the study, the patient clearly benefits from positive airway pressure therapy. At this time, CPAP pressures of 14 to 15cm would be recommended along with Respironics Comfort Fusion nasal CPAP mask, a chin strap as well as heated humidification.

When reading the backup charts, even when the CPAP was at 13, while Supine, I "slept" for 59 minutes and had an AHI of 16.

Heading everyone's advice, I have ordered the UM Full Face and the Mirage Swift LT pillows to see if I can tolerate these better.

[jnk]

Don't forget to change the mask setting in the machine when you change masks.

Once you have a mask that you are comfortable with, that is consistently not leaking (and you aren't having any mouth leaks, in the case of the nasal pillows), and once your body is used to PAP therapy, THEN you can begin looking at the data for an entire WEEK before deciding whether to mess with the pressures. Don't change the settings every night. There are too many variables to judge by what happens on one night. At least a week of data is needed. So wear one mask all week at the same settings and see what your numbers are then.

Many set their autos a cm or two above and below their titrated pressure. That gives them some of the benefits of using an auto while still making sure the pressure is high enough.

Concentrate on getting AI down first before worrying about AHI or HI.

You are well on your way.

[Tallen234]

I actually like the F&P mask. I like the fact that you can fit your chin into the mask to provide additional support for the mask. I am relatively comfortable with it. The DME actually recommended it over the UM FF because of the chin support.

My agitation/concern arises from the sleep study recommendations of 14-15 cm, even though they only titrated me to 13. Then, when I got the machine, it was dialed in at 7-14.

I admit that I am "fiddling" a bit too much with everything, but this is partially due to getting my sleep study results. What if I set the machine to 12-16 and run with this setting for a week? Does this make sense given the sleep study recommendations? Or should I run a straight CPAP at 14?

If I can't get things under control soon, I am considering seeing a sleep specialist in the area, as I have very little confidence in the man behind the curtain (the doc attached to the sleep study) and my PCP (who is great, but is not a sleep doc).

Thanks again! This board is great!

Don't forget to change the mask setting in the machine when you change masks.

Once you have a mask that you are comfortable with, that is consistently not leaking (and you aren't having any mouth leaks, in the case of the nasal pillows), and once your body is used to PAP therapy, THEN you can begin looking at the data for an entire WEEK before deciding whether to mess with the pressures. Don't change the settings every night. There are too many variables to judge by what happens on one night. At least a week of data is needed. So wear one mask all week at the same settings and see what your numbers are then.

Many set their autos a cm or two above and below their titrated pressure. That gives them some of the benefits of using an auto while still making sure the pressure is high enough.

Concentrate on getting AI down first before worrying about AHI or HI.

You are well on your way.

[Tallen234]

Small bump. Do you think my "plan" is reasonable? Trying 12-16 for a week? Especially given the recommendations of my titration study?

I admit that I am "fiddling" a bit too much with everything, but this is partially due to getting my sleep study results. What if I set the machine to 12-16 and run with this setting for a week? Does this make sense given the sleep study recommendations? Or should I run a straight CPAP at 14?

Thanks again! This board is great!

Don't forget to change the mask setting in the machine when you change masks.

Once you have a mask that you are comfortable with, that is consistently not leaking (and you aren't having any mouth leaks, in the case of the nasal pillows), and once your body is used to PAP therapy, THEN you can begin looking at the data for an entire WEEK before deciding whether to mess with the pressures. Don't change the settings every night. There are too many variables to judge by what happens on one night. At least a week of data is needed. So wear one mask all week at the same settings and see what your numbers are then.

Many set their autos a cm or two above and below their titrated pressure. That gives them some of the benefits of using an auto while still making sure the pressure is high enough.

Concentrate on getting AI down first before worrying about AHI or HI.

You are well on your way.

[ozij]

You split night study was done in order to save the insurance company some money - and it turned out they didn't have time to do a full titration study. You could try insisting on a full night insurance paid titration, so they can take you to as high a pressure as necessary, without the guess work. Or you could use your machine to titrate yourself.

Higher pressure makes leak management more difficult. You have to learn to sleep with the mask, you have to learn what to do to keep it from leaking - leave the pressure alone for a week and concentrated of getting the mask to seal comfortably. An uncomfortable mask may cause arousals that confuse the heck out the automatic pressure dajustment.

Because the sleep study was flawed, and you hardly slept, it may turn out that for most of your natural sleep time you need lower pressure, and you need the high end of the range only when you're supine. It may also turn out that you need higher pressure consistently once you sleep deeply - no one knows anything for sure at this point. The person who analysed your data was thinking in terms of fixed pressure that has to work in the worst case. On an auto you don't have to force the minimum pressure to the worst case scenario.

I am still tired in the morning, wake up about 2-3 times a night and am developing a pressure sore on the bridge of my nose.

Not surprising given the leaks on the one hand, and the pressure changes on the other.

O.

[Tallen234]

I've actually had three studies. My first, I didn't sleep. Second, they confirmed OSA. Then my third study was the titration study. I had a hard time sleeping through all of them.

The past three nights, I really haven't had any problems with leaks. I just wake up a few times and I now have a pressure sore on my nose.

Looking at the results, there wasn't any correlation between supine and more apneas. At one setting I had more when on my side than when supine. At other, visa-versa.

It's almost like they got to 13cm and didn't have time to try anything higher.

You split night study was done in order to save the insurance company some money - and it turned out they didn't have time to do a full titration study. You could try insisting on a full night insurance paid titration, so they can take you to as high a pressure as necessary, without the guess work. Or you could use your machine to titrate yourself.

Higher pressure makes leak management more difficult. You have to learn to sleep with the mask, you have to learn what to do to keep it from leaking - leave the pressure alone for a week and concentrated of getting the mask to seal comfortably. An uncomfortable mask may cause arousals that confuse the heck out the automatic pressure dajustment.

Because the sleep study was flawed, and you hardly slept, it may turn out that for most of your natural sleep time you need lower pressure, and you need the high end of the range only when you're supine. It may also turn out that you need higher pressure consistently once you sleep deeply - no one knows anything for sure at this point. The person who analysed your data was thinking in terms of fixed pressure that has to work in the worst case. On an auto you don't have to force the minimum pressure to the worst case scenario.

I am still tired in the morning, wake up about 2-3 times a night and am developing a pressure sore on the bridge of my nose.

Not surprising given the leaks on the one hand, and the pressure changes on the other.

O.

[jnk]

Frankly, I like the range they chose, 7-14. But that's just me. I would try that range for a week or two as I got used to PAP.

It is relatively common for the tech to find the pressure that does the job and then for a cm or two to be added to that number just 'for good measure,' in case you were having a particularly "good" night on the night of the titration study.

The advantage to an auto is that it can stay at a low pressure much of the time then raise the pressure when it needs to. (The disadvantage, I believe, is that jumps in pressure can cause sleep arousals, especially at first.) Most here feel a low of 4 is too low, since it is hard to breathe at that low of a pressure for some. So I think it is good, amazingly insightful of whomever set the initial pressure, that they raised that minimum up to 7. There are reasons, to my way of thinking anyway, not to start with a minumum at 10 or above on a ResMed auto.

So I would give the machine that wide range of 7-14 to let it titrate, and then I would restrict that range later on as I saw what happened over the weeks. After I was happy and successful with my mask, that is. Then I would post results to get the reactions from the ones in the forum more experienced than jnk.

It seems to me that your instincts are great, and it's good to see that you're chomping at the bit. But I would slow down. Trot before you gallop.

[Tallen234]

Great advice. I will heed it. Last night was pretty horrible. I ran the APAP 11.2 to 16 and I couldn't sleep. Not sure if it was the increased pressure, but it was a bad night. I am going back to 7-14 for next week and see what happens.

My father-in-law had an instant reaction to CPAP therapy, so I was hoping for a quick turnaround. I guess I need to be a bit more patient!


Thanks!

Frankly, I like the range they chose, 7-14. But that's just me. I would try that range for a week or two as I got used to PAP.

It is relatively common for the tech to find the pressure that does the job and then for a cm or two to be added to that number just 'for good measure,' in case you were having a particularly "good" night on the night of the titration study.

The advantage to an auto is that it can stay at a low pressure much of the time then raise the pressure when it needs to. (The disadvantage, I believe, is that jumps in pressure can cause sleep arousals, especially at first.) Most here feel a low of 4 is too low, since it is hard to breathe at that low of a pressure for some. So I think it is good, amazingly insightful of whomever set the initial pressure, that they raised that minimum up to 7. There are reasons, to my way of thinking anyway, not to start with a minumum at 10 or above on a ResMed auto.

So I would give the machine that wide range of 7-14 to let it titrate, and then I would restrict that range later on as I saw what happened over the weeks. After I was happy and successful with my mask, that is. Then I would post results to get the reactions from the ones in the forum more experienced than jnk.

It seems to me that your instincts are great, and it's good to see that you're chomping at the bit. But I would slow down. Trot before you gallop.

[Snoredog]

if you need 14 or 15 cm pressure, it DEPENDS on what you need that pressure for. If you need that high a pressure to eliminate apnea, it isn't going to happen with that particular machine in the Auto mode, the result will be a higher AI and HI.

AI is the only number you should be concerned with at this point. HI will fluctuate up and down depending on what AI does, if AI is totally eliminated with the bottom or minimum pressure then additional pressure can work on lowering the HI.

Because of the way that machine works, it won't respond to frank apnea above 10 cm pressure. That is the reason you have to use the Minimum pressure setting to manually address the AI. Increase Minimum pressure to 10 cm. Set Maximum pressure to 18 or 20.

Because of your pressure requirement to control apnea, you are essentially using your Autoset as a CPAP in manual titration mode.

[jnk]

. . . my sleep study, which is very complicated . . .

I know you spoke of your latest sleep study as "flawed," but the knowledgeable longtime posters here, like ozij Snoredog and a host of others, may still be able to make some useful observations if you can post more specific details of the results from the studies.

Only a thought.

At the very least, it might be entertaining and would give you something to do to keep you from playing with the adjustments all day.