Adjusting my Clinical Pressure Settings

[jda1000]

Hi -

On cpap.com I saw a blurb (I failed to grab the link to it, sorry) that said CPAPers removed their masks because they weren't getting enough air.

I remove mine just about every night. At first, it was after a couple hours, but I'm up to about three and a half now, after three weeks.

In the morning, I do recall removing it, but not WHY - lacking air makes sense.

So is increasing one's pressure the only way to increase air volume with these wee compressors?

I'm feeling quite a bit better with just the 2-3 hours of proper sleep (it is, after all, a 2-3 hour increase!), and for some reason am hesitant to change the pressure.

I'm at 7, with a ramp start of 4, a ten-minute ramp, EPR of 3, and and EPR inhale-recovery of "fast."

[Wulfman]

Hi -

On cpap.com I saw a blurb (I failed to grab the link to it, sorry) that said CPAPers removed their masks because they weren't getting enough air.

I remove mine just about every night. At first, it was after a couple hours, but I'm up to about three and a half now, after three weeks.

In the morning, I do recall removing it, but not WHY - lacking air makes sense.

So is increasing one's pressure the only way to increase air volume with these wee compressors?

I'm feeling quite a bit better with just the 2-3 hours of proper sleep (it is, after all, a 2-3 hour increase!), and for some reason am hesitant to change the pressure.

I'm at 7, with a ramp start of 4, a ten-minute ramp, EPR of 3, and and EPR inhale-recovery of "fast."

With a pressure of 7 and an EPR setting of 3 (EPR drops the pressure by actual cm of pressure per setting number), you're only getting about 4 cm. of therapy pressure about half the time and 7 cm. the other half..

I'd be suffocating at those pressures......but, in answer to your question....."Yes".....raising pressure/changing EPR/eliminating Ramp would be ways to increase your "effective" pressure.
Your profile shows you have a data-capable machine......what are your data numbers like?


Den

[jda1000]

I think I lucked out and got a great machine without, at that time, knowing anything about them. But I don't yet have a card reader; for now I'm just writing the numbers down - which I've learned to do before noon!

My numbers seem relative stable:

AHI - 4 - 4.5
AI - 0
HI - 4-ish.
Leakage rate - .36 to .7 l/s, usually near 0.4, and at .2 last night - tighter straps on lower mask. The RT says she's mailing me a different mask, but I'm unsure about that - I feel I'm adapting to this one and am loathe to give up a night's sleep to try another.

*
I felt suffocated before dozing off early on, but thought it an issue of adapting - and am used to it now. I consciously take long, deep breathes until I fall asleep.

"Fast"EPR recovery, as opposed to "medium," helped a lot.

EPR at 3 was much better than at 2.

Seems to suggest I need more pressure and a bigger EPR!

So - I'll experiment. I think if I could learn to keep the mask on all night, I'd be dialed in, for now.

[Hawthorne]

I would think that raising your lower pressure and raising the ramp pressure would help a lot when you are using the max EPR setting. There needs to be enough air coming into the mask to help blow out the CO2 efficiently when you exhale or many cpap users do feel like they are suffocating. Sometimes they even wake up with headaches from rebreathing the CO2 because it doesn't get out of the enclosed mask area fast enough. Remember that the mask is a confined area that the CO2 you are exhaling needs to be flushed out of. The concentration of CO2 is greater in that small area in the mask (without cpap that CO2 is breathed out through a whole room immediately!). Makes sense, to me that a goodly pressure would be needed to keep that CO2 moving on out. I would have the ramp at 6 cm at least, especially when you are using EPR at 3. You might be able to keep the mask on longer too, by raising your minimum pressure to 8 cm. I double you will find that too high. If you discover you are not feeling that suffocating feeling as much - but still some - you may want to raise it another cm (both ramp and minimum pressure). You could also go 1/2 cm at a time.

The other alternative would be to lower your EPR by 1 - from 3 to 2. I might even do that as well as raise the pressure slightly. Now i'm thinking out loud so will stop!

[jda1000]

I think tonight I'll test the system with my pressure at 8 and my ramp starting point at 5.

If I understand correctly, with a pressure of 8 and an EPR of 3, my exhalation pressure will be 5, as well.

We'll see how it goes. I haven't had any headaches or other signs of CO2, other than pulling the mask off without waking.

I did notice, when I first signed up here, that my pressures were considerably lower than many members, but frankly counted it as a good thing; I assume a lower pressure means less force required to keep the airway open means less collapsing of the soft tissues, and overall less stress to my physiology.

[Hawthorne]

You got it! I think this is a good beginning adjustment for you. Remember it takes 4 nights to a week to assess any adjustments you make so stay with this one for 3 or 4 days anyway and see if you find an improvement. I think you will. Hopefully it will mean keeping your mask on longer too. You may want to make further adjustments after that.

[jda1000]

New settings and results:

bottom of ramp = 5
top of ramp = 8 = 'pressure'
ramp time = ten minutes
usage: 4:59 (this is four hours and 59 minutes, right?)
AI = 0.0
HI = 4.8
Leakage = 0.26 l/s

That's my best sleep yet, but it was split: I retired at about 10.30 and woke fully and completely at 2 a.m. feeling alert thought it was proper morning.

Then I realized it was 2, not 6; the furnace noise had wakened me, and I was ravenously hungry. Sleep would not return, so I had a bit of toast and mint tea, and returned to bed about three.

I put the mask back on - the benefit of waking fully, instead of just enough to remove the mask.

I slept fitfully until about 6; I could not sleep on my side due to bad leaks, so moved the pillows I use to keep on my side and just slept on my back, which I don't generally like or do - and never have.

I slept fitfully without the mask until about 9.

That's the night.

I did NOT use AmbienCR, but did manage to fall asleep, which I consider a very positive sign.

**
Overall, I feel rested enough to live, but not as rested as a few nights ago when I slept deeply with the mask on for about three hours, and deeply without it for another three or four.

**
I'll leave the pressure setting where it is - 8 but as I am generally awake at the end of ramping and it does not bother me,
I think I'll just turn that off, unless there's some therapeutic reason to use it, of which I'm not yet aware.

[Hawthorne]

It does take a few days for differences to appear with a pressure change. Yes, that is 4 hours and 59 minutes.

With your low pressure, I don't think you need ramp at all. Just my opinion but, I would turn off ramp.

Is that the first night you have not used the AmbienCR? Falling asleep easily without it is a good thing.

If it were me, I would leave things as they are (except for disabling ramp) and see how the next couple of nights are.

[LoQ]

I agree with you, you don't need the ramp.

I also wonder why you need the EPR. Your pressure is so low. Turn it off and see how it goes.


I always have trouble breathing with a mask on, so I use Breathe Right strips. I want to tug the mask down to get it out of my eyes, but it ends up putting pressure on my nose in such a way that I feel like I can't get air.


As for waking up hungry, that should not be happening. Recommend you seriously consider eating 3-4 ounces, at least, of protein just before bedtime.

[Kiralynx]

As for waking up hungry, that should not be happening. Recommend you seriously consider eating 3-4 ounces, at least, of protein just before bedtime.

Some people find that eating just before bedtime result in reflux. However, I agree that waking up hungry is not usual. This could be a sign of major shift in body mechanisms and some healing going on.

For about five months after my cancer surgery, I had to keep cans of tomato juice and some Larabars by the bed because I would wake 2-3 times a night to take my anti-inflammatories, and then eat something because I was ravenous.

About the time the ravenous started to taper off, I was diagnosed, got my Bipap, and the healing started all over again. Three months on Bipap, and I'm finally sleeping through the night for the first time in almost 8 years... wow.

[jda1000]

I've been at 8 for three or four nights now; last night I slept straight through for 8 continuous hours without stripping off the mask.

I consider the pressure increase a success (though it seems this therapy seems to be an evolutionary process), and appreciate the tip.

I have not turned off the EPR, but may try that later - after a few nights of decent rest. I found having it set on "fast" rather than "medium" was helpful, so am hesitant to shut if off. Is there a clinical benefit to doing without?

[rested gal]

I have not turned off the EPR, but may try that later - after a few nights of decent rest. I found having it set on "fast" rather than "medium" was helpful, so am hesitant to shut if off. Is there a clinical benefit to doing without?

Rather than turning EPR off, you might want to first see how it feels at various EPR settings during the day while lying in bed awake. Try EPR at 1, 2, 3, and off. Pick what feels comfortable to you for breathing out.

I personally would want to set my cpap pressure up one cm for each EPR setting I decided to use. In other words, if my prescribed pressure were 7, and I wanted to use EPR, I'd set my cpap pressure this way:

EPR 1 -- I'd set the CPAP at 8
EPR 2 -- I'd set the CPAP at 9
EPR 3 -- I'd set the CPAP at 10 (or 9)

But that's just me, and I'm no doctor. I'd just rather have my prescribed pressure being used when I'm exhaling with EPR. Since EPR drops the pressure one cm for each EPR setting, I'd want to change the CPAP pressure so that "prescribed pressure" (or close to it) was in place all through each exhalation and during any pause at the end of exhalation.

If you do decide to turn EPR off completely, you'll probably find that it might feel like a bit of effort for the first minute of so of breathing out with no pressure relief. But after a few minutes of relaxed breathing, you may be surprised at how easy it feels to breathe out compared to how it felt at first.

[Sleeptech010110]

Three things...

1) EPR is a patient comfort setting, it lowers the pressure so it's easier to exhale, then cranks it back up for the inhale to prevent any apnea's. The chance of it causing an apnea and your pressure needing to be raised to compensate is incredibly low.

2) Your oxygen levels are monitored during a study. All masks are designed with a considerable leak, a CO2 buildup will usually only happen if you cover the masks vent port. If a freak build up had occured during your study at the pressure they set you on, it would have registered immediately.

3) A CPAP unit is like any other medical device or medication, it's prescibed to you with a dosage rating. If your doc/medical supplier tells you that you can adjust you dosage, ie., pressure settings, within a certain range, to be more comfortable, more power to you. But exceeding the pressure high can be worse than being to low. It only takes 1cmH2O of excess pressure to cause central apnea's, basically meaning the pressure is preventing you from breathing.

If your Titration study was run by even a halfway competent PSGT, your medical supplier should have a specific range for you. Please make sure you're not exceeding your maximum pressure. Everyone's is different.

That said, if you're still going to play with your pressures, please talk to your doctor/medical supplier first. And please, please be very careful. I don't know what the medical suppliers tell patients when they instruct them on using the machine, but on the clinical testing side, the pressures we determine are considered definate. Anything too high or too low, dangerous. A patient messing with their prescription, deadly.

[Wulfman]

Three things...

1) EPR is a patient comfort setting, it lowers the pressure so it's easier to exhale, then cranks it back up for the inhale to prevent any apnea's. The chance of it causing an apnea and your pressure needing to be raised to compensate is incredibly low.

2) Your oxygen levels are monitored during a study. All masks are designed with a considerable leak, a CO2 buildup will usually only happen if you cover the masks vent port. If a freak build up had occured during your study at the pressure they set you on, it would have registered immediately.

3) A CPAP unit is like any other medical device or medication, it's prescibed to you with a dosage rating. If your doc/medical supplier tells you that you can adjust you dosage, ie., pressure settings, within a certain range, to be more comfortable, more power to you. But exceeding the pressure high can be worse than being to low. It only takes 1cmH2O of excess pressure to cause central apnea's, basically meaning the pressure is preventing you from breathing.

If your Titration study was run by even a halfway competent PSGT, your medical supplier should have a specific range for you. Please make sure you're not exceeding your maximum pressure. Everyone's is different.

That said, if you're still going to play with your pressures, please talk to your doctor/medical supplier first. And please, please be very careful. I don't know what the medical suppliers tell patients when they instruct them on using the machine, but on the clinical testing side, the pressures we determine are considered definate. Anything too high or too low, dangerous. A patient messing with their prescription, deadly.

I don't think you have any idea about that which you speak. And, I wonder about your expertise as a sleep tech (as your user name implies).
Since EPR is similar to or almost like a "mini bi-level machine" (it drops the pressure the amount of cm. per its setting number), AND in bi-level titration the EPAP pressure is set to eliminate the apneas, a 3 cm. drop from where this person's machine was set (and probably his prescribed pressure), then this person is NOT getting their prescribed pressure for half of the night while he's exhaling.

What about the doctors that OVER-prescribe pressures?
So, it's alright for doctors, RTs, Sleep techs, and DMEs to screw up when prescribing and setting pressures, but when a patient (user) tries to find a "better" pressure to lower their events or get a better night's sleep.....THEN it becomes "deadly"?????

Try selling your load of crap about tweaking their therapy to people with diabetes who have to do it every day.

DON'T DO THAT! DON'T TOUCH THIS! YOU'LL KILL YOURSELF! THE SKY IS FALLING!!!

People like you give the "knowledgeable professionals" in this business a bad name.

Den

[ozij]

The number of deadly prescriptions we've run into on this forum is very impressive. Deadly because they were dead wrong, and made cpap intolerable for the users.

Suppose a person raises the pressure 1 cm too high, suppose further, that person does indeed get pressure induced apneas as a result. The get up the next morning. Say: hmmm, this was not so good. Look at there data, notice that they have more events - and drop the pressure back. They do not remain stuck forever on one mistaken number. On the other hand, suppose a person a person's sleep on the PSG night was very different from their usual. They are given a pressure Rx base on that very exceptional night. The can't track their data, the don't make changes.... they are sent home and are expected to stick to that pressure for moths. They try it, and they stuff the machine in the closet after a week of trying.

Deadly? Too much insuline is deadly - but people decide on their own dose.
The one study that will never be done is a comparison of the health of people who change their own pressure with those who put the machine in the closet. And it won't be done because it would be immoral not to try and convince the second group to resume therapy.

By the way, people are not "playing with their pressures" they are changing slowly and systematically. The pressure changes happening on PSG nights are far more abrupt, violent and disrupting than what people do to themselves.

O.