Adjusting my Clinical Pressure Settings

[jnk]

. . . increasing the EPAP if you're using EPR?! . . .

Would you agree, in principle, that if a patient had permission from the sleep doc to self-titrate, and that patient found that increasing EPR on their ResMed CPAP caused an increase in the AI (consistently over a week or two), that patient might think about slightly raising the CPAP pressure to see if that brought AI back down?

Many patients here, in cooperation with their sleep professionals, have set their pressure(s) based on weekly data, instead of using the 1-2 cm cusion above what worked on titration night.

[ozij]

I have and I know what it feels like! I have worn it for a night. It's not a lot of fun.

Good!

I know a lot of you know that if you increase the pressure too high you can start having central apneas, so I was just shocked to see you suggesting the increase.

Well, if it turns out there's too many apneas at the higher pressure, the pressure can be lowered. Is there any reason to think central apneas are worse than obstructives? The aim is to have neither - and find the right pressure combination to do the job.

By the way, it was an IPAP increase that was suggested. The EPAP is reduced by EPR, and if you want to keep a 3 cm. differntial, and not have your EPAP too low, you have to raise the IPAP (both terms which don't actually appear on a fixed pressure machine, but are very useful for this discussion).

O.

[WichitaSleepRT]

. . . increasing the EPAP if you're using EPR?! . . .

Would you agree, in principle, that if a patient had permission from the sleep doc to self-titrate, and that patient found that increasing EPR on their ResMed CPAP caused an increase in the AI (consistently over a week or two), that patient might think about slightly raising the CPAP pressure to see if that brought AI back down?

Many patients here, in cooperation with their sleep professionals, have set their pressure(s) based on weekly data, instead of using the 1-2 cm cusion above what worked on titration night.

What I would try first is turning the EPR off. If the AI continued to be high, an increase in pressure may be warranted.
If a doctor gave you permission? I have yet to meet one that advocates for patients to adjust their own pressure, there is a lot of liability to go along with that. Apart from that, if the doc says do it go for it. In most sleep studies, patients are tried on higher pressures than they are prescribed on. If the doc knows what pressure started to give you centrals and tells you to avoid it, I see no harm.

[jnk]

. . . If the doc knows what pressure started to give you centrals and tells you to avoid it, I see no harm.

A lot of sleep docs we hear about on this board have no trouble with their patients being handed autos set wide open, 4-25 cm, and then letting the machine decide moment-to-moment, every night. An occasional central may occur using an auto or raising pressure on a CPAP. But the body adjusts. When a patient reads the numbers every morning, sees week-long trends, and learns the science of self-titrating, the patient learns quickly to find the sweet spot with the fewest apneas, hypopneas, or flow limitations, of any sort, at the lowest pressure. The patient can dial that pressure in, or in the case of an auto, dial in the best range. A number of sleep docs and RTs are coming on board with that kind of patient involvement. You may find that researching posts on this board on that very subject will be interesting to you.

BTW, nice having you here.

jeff

[ozij]

...and a misnterpreting, wide open autopap can create runaway pressure, being driven on a vicious cycle. The result is not death. It it simply being jolted wide awake and breathless, with a hurricane in your mask. Normal beginners response? Take mask off (throw it off...), turn machine off (try not to use sledge hammer), and go back to sleep without it.

Speaking of liability -- the only place I ever saw a patient's medication being kept under lock and key, and handed under strict control was in a psychiatric hospital.
Even insuline -- too much of which can kill you -- is given to patients to use as needed.
CPAP pressure is not Ventilator pressure.
O.

[Wulfman]

I just read this thread and I'm thinking "wow" these people suggest increasing the EPAP if you're using EPR?! By the time you are done exhaling, ie typically when apneas happen, the C-Flex/EPR cycle is finished and the pressure is already back to the prescribed level. I know a lot of you know that if you increase the pressure too high you can start having central apneas, so I was just shocked to see you suggesting the increase.

With EPR technology, there are two ways to increase the "minimum" (EPAP) pressure on exhale.....either lower the EPR number or raise the actual pressure setting.

Yeah, we "shock" lots of people in your profession who discover this site for the first time. We're big on people getting data-capable machines and monitoring their own therapy (preferably with software). After all, it is OUR therapy.
One night of lousy sleep in a sleep lab doesn't give a good representation of how we sleep in our own beds, either. We also realize that the machines use air flow to make their decisions and that may not be quite on par with some sleep lab setups, but when it's taken over a period of time, it comes pretty close. "Everything's relative".

Air pressures at both "extremes" can either be unhealthy or uncomfortable. I have yet to hear of anyone who has died of pressure-induced Central Apneas, but people at the other end of the spectrum (LOW pressures) will still be having too many apneas, too......and if they're mouth-leaking or mouth-breathing, using a nasal mask their therapy is essentially being nullified.

Probably the vast majority of people who come to the forums have been mistreated in many ways by the medical, insurance or DME professions. They're looking for information that was withheld from them in some manner or other. Many were prescribed "wrong" pressures (both ways), el cheap-o equipment and no instructions.
This therapy isn't a "scam", but the professions trying to capitalize from it seem to make it appear that way.

The failure rate is a "SHAME" on the professions involved.

We're just trying to fill in where others have failed.

But, welcome to the forum.


Den

[jnk]

. . . the only place I ever saw a patient's medication being kept under lock and key, and handed under strict control was in a psychiatric hospital. . . . .

Now THAT sure brought back some memories for me! Thanks, O.

[WichitaSleepRT]

A lot of sleep docs we hear about on this board have no trouble with their patients being handed autos set wide open, 4-25 cm, and then letting the machine decide moment-to-moment, every night. An occasional central may occur using an auto or raising pressure on a CPAP. But the body adjusts. When a patient reads the numbers every morning, sees week-long trends, and learns the science of self-titrating, the patient learns quickly to find the sweet spot with the fewest apneas, hypopneas, or flow limitations, of any sort, at the lowest pressure. The patient can dial that pressure in, or in the case of an auto, dial in the best range. A number of sleep docs and RTs are coming on board with that kind of patient involvement. You may find that researching posts on this board on that very subject will be interesting to you.

BTW, nice having you here.

jeff

This is assuming that the patient has an auto, from what I can remember the OP does not.

From what I have read on this board there are a lot of you that are informed and have enough "smarts" to do just as you say. But trust me there are far more out there that don't have a clue what an apnea is! They only know that they have sleep apnea. And should leave the xPAP alone!

Thanks for saying "nice having you here" but the responses I have received so far have not been so nice. After today I'm signing off as there are enough "cooks in this kitchen!"

[Wulfman]

Another thought that came to me as I exited that thread......
Go through the pages of the forum and scan down through the titles of the threads and see how many are from "newbies" who NEED "help"........and haven't gotten it from the normal channels.

Doctors are expensive......DMEs have rules to follow as far as helping the customers (many have stupid employees)......and many insurance providers are just plain wasteful with OUR money (and also have stupid rules).

Den

[jnk]

. . . Thanks for saying "nice having you here" . . .

I meant it. And still do. In this kind of forum, the more cooks the better.

Many find that self-titrating goes very well with a straight CPAP, as long as it is data capable. And the goal here is to educate, not convince people they should ignore the professionals.

We have a long history here of RTs stopping by, being shocked by what they read, and moving on. It can appear as if one is getting ganged-up on when some of us who have had rough experiences with DME's vent. But your views are respected, and this forum has a lot of lurkers who benefit from the free-flow of ideas.

The industry is changing. Maybe for the good. Maybe not. But it IS changing. And this is a good place to keep an eye on what is going on and have a good time joking around with us crazies and talking about things that matter all at the same time.

You are welcome here now, and you always will be.

jeff

[Wulfman]

From what I have read on this board there are a lot of you that are informed and have enough "smarts" to do just as you say. But trust me there are far more out there that don't have a clue what an apnea is! They only know that they have sleep apnea. And should leave the xPAP alone!

Thanks for saying "nice having you here" but the responses I have received so far have not been so nice. After today I'm signing off as there are enough "cooks in this kitchen!"

That is VERY TRUE! However, there's a disconnect in how much information patients are given, even if they WANT to know more. The "professionals" try to treat us ALL the same (like we're stupid and shouldn't know anything about it). It appears to be a "control" issue on their part. For those of us who wanted to know more, we sought out the information on the Internet. There are forums for just about everything and anything on the Internet.
How come I don't see the "professionals" over on the diabetes forums acting SHOCKED that there are diabetes patients taking control of THEIR own therapy.

In case you haven't spent much time here, there are actually (and have been) quite a few "professionals" (sleep techs, DMEs, doctors, etc.) who frequently read and contribute to this forum.
So, don't let your feelings get hurt......stick around.


Den

[jda1000]

Ditto on the sticking around - I personally like having lots of cooks here. The more, the merrier. It's rather a collaborative process, here....

[anotherRandy]

And the literature with the machine describes the EPR feature mostly as a "comfort" feature - not something that reduces or enhances clinical aspects of treatment, aside from improving compliant use of the machines.

Maybe, or maybe not. My tech suggested I reduce my EPR down one setting. She hypothesizes that EPR acts like a "mini bi-pap." I did so last night and it made a huge difference in my numbers. We'll see if it carries forth into the future.

[DoriC]

I'm glad I didn't see this thread 6months ago, words like "kill and "deadly" would have scared me away. And I can assure you "these people" here don't "play with their settings". This is a serious business and the advice and information given are very well thought out. Those that don't have the answers just give encouragement and defer to the front-line veterans who have saved many of us from non-compliance. The medical community certainly is lacking. BTW, you're welcome to participate, I'd like your input.

[rested gal]

By the time you are done exhaling, ie typically when apneas happen

I agree.

You don't need 7cm of pressure when you first begin exhaling, only when you are at the end of exhaltaion and through inhilation.

I agree.

the C-Flex/EPR cycle is finished and the pressure is already back to the prescribed level.

I agree with half of that. That's how Respironics' C-flex works. But that's not how ResMed's EPR works.

Taking a deep breath here, 'cause I can sure be wrong. All this is going to be just my layperson's opinion. I've used machines with C-Flex and machines with EPR. And read quite a bit about them. Doesn't mean I understand them, though...but anyway, here goes...

Many people, not just you, WichitaSleepRT think C-Flex and EPR behave the same way other than that C-Flex gives a vague drop dependent on the force of a person's exhalation and EPR gives an exact number of cms of drop. But that's just one difference in how they were designed to go about the job of making exhaling more comfortable.

Here is a crucial difference between those two manufacturers designs for exhalation relief, the way I understand it:

Respironics' C-Flex does, indeed, let the pressure already be in place before exhalation is completely finished. ResMed's EPR, however, maintains its drop at the end of exhalation and even AFTER exhalation is over.

As you said, the amount of pressure drop C-flex gives is very dependent on the force of the person's exhalation...at the beginning...when the person STARTS breathing out. Breathe out hard, and C-flex drops more than if you breathe out lightly. C-flex does not maintain the drop in pressure all the way to the very end of the exhalation. When the Respironics machine senses that the exhalation is beginning to dwindle or lose its force, the regular pressure begins coming back in. With C-flex, the "prescribed" pressure is, indeed, in place before the person would start to inhale again.

ResMed's EPR, on the other hand, gives only a small drop at the beginning of exhalation and moves the pressure down as the exhalation continues. The full drop with EPR doesn't happen at the beginning of exhalation. The full drop, whether the setting is 1, 2, or 3 cms, happens as the exhalation continues and stays down at the end of exhalation and throughout any pause at the end of the exhalation. EPR keeps the pressure down UNTIL the person actually starts to inhale again. Breathing in again is EPR's trigger to let the prescribed pressure come back.

You can try that out, WichitaSleepRT. Get hold of a ResMed machine, set the pressure at 7 and set EPR at 3, for a 3 cm drop. Breathe with it a few times, then..at the end of one of your exhalations, hold your breath. And hold it and hold it and hold it. Count off 15 seconds, but don't inhale. At the end of the 15 seconds of breath-holding-after-exhaling, you'll feel the machine switch up to pressure of 7.

So, if an apnea has happened at the end of exhalation, or during a pause before inhalation, the person might not be able to inhale. EPR will still be keeping the pressure down the exact number of cm drop (1, 2, or 3 cms) it's been set for, and will wait, and wait, and wait -- even during any pause after the end of exhalation -- waiting to sense that the person actually starts to inhale again.

Inhalation is the trigger that makes EPR stop holding the pressure down and allow the "prescribed" pressure back in. With an apnea in place, the person can't initiate a breath. EPR is not going to let the pressure go back up until the person does start to inhale. A real catch-22. ResMed knew that could happen, so they built in a safeguard for that scenario.

The safeguard is this: if 15 seconds go by after exhalation is finished, and the person has still not started to inhale (an apnea could sure keep a person from being able to inhale) the ResMed machine will finally stop waiting for an inhalation to trigger EPR to stop holding the pressure down. After 15 seconds of no breathing in, the machine will suspend EPR and go back up to the prescribed pressure. After that little episode, there will have to be at least one more another normal inhalation, before EPR will start doing its thing again.

From ResMed's site:
http://www.resmed.com/en-us/products/fl ... =products2
EPR Timeout
If a patient's exhalation period exceeds 15 seconds, EPR immediately suspends. The treatment pressure reverts to set CPAP and remains suspended until the next inhalation phase is detected.

From Respironics' site:
http://cflex.respironics.com/
C-Flex pressure relief technology makes sleep therapy more comfortable by reducing pressure at the beginning of exhalation and returning to therapeutic pressure just before inhalation.

If a person's prescribed pressure happens to be right on the line, so to speak, for preventing apneas, then EPR set for one or two or three exact cms below that mark may let some apneas get well underway before the person can even get the next inhalation started. Without an inhalation STARTING, EPR is going to hold the pressure down, at a subtherapeutic level, for at least the 15 seconds that it takes before EPR says, "Whoops, this person is taking too long to inhale again...maybe they're having an apnea...I'd better let the regular pressure back in!"

I don't mean to make a big deal of that, even though it sounds like I am. LOL!! Just trying to explain the difference between when the "prescribed" pressure is there, and when it's not, with C-Flex and with EPR, as I understand it. I could be wrong.

Most people's prescribed pressure is probably not going to be right on a "straw that broke the camel's back" line of pressure that prevents most apneas, anyway. It's very likely that their sleep study came up with a pressure than was a little higher than what it takes to prevent their apneas. A titration is likely to have gone up more than just to a point that prevents apneas. A titrated pressure is likely to be a little (maybe a lot) higher than just what it takes to prevent apneas. Higher, in order to also knock out hypopneas and lesser flow limitations, and residual snores.

But if I'm going to use EPR, I don't think it's a bad idea to up the prescribed pressure a cm or two...just in case.

From what I have read on this board there are a lot of you that are informed and have enough "smarts" to do just as you say.

We're all trying, as best we can. I'm wrong a lot, but I do like learning.

But trust me there are far more out there that don't have a clue what an apnea is! They only know that they have sleep apnea. And should leave the xPAP alone!

I agree. Most cpap users out there probably don't have the least bit of desire to learn about their disorder or about the treatment for it, other than, "Where's the on/off switch?" Unfortunately about half of CPAP users turn the machine off permanently. My hat's off to you, WichitaSleepRT, for working with them every day, trying to help them. You obviously do care, or you wouldn't have bothered to offer your thoughts and opinions in this thread.

Thanks for saying "nice having you here" but the responses I have received so far have not been so nice. After today I'm signing off as there are enough "cooks in this kitchen!"

Well, I hope you'll stay. I think you received quite a few polite responses. I think it's always good to see and discuss a range (no pun intended!) of opinions. That's how we all keep learning.

My edit: The "15 seconds" I kept mentioning begins the countdown from when exhalation starts. The countdown doesn't begin at the end of exhalation, which is what I thought when I wrote the post.

Depending on how long a person's exhalation lasts, there will be a varying number of seconds (probably about 10 - 13 seconds for most people) remaining in the "15 seconds" by the time exhalation is finished and during the pause before the person tries to breathe in again.