Starting out with high pressure

[Sleepless in Indiana]

Hi folks,

I have just found this place, as well as just having been confirmed to have sleep apnea. I knew for some time that I most likely had a problem. Well I just saved up the money to have the sleep-test done. The results are in and they want to start me out at 20 cm h2o. From what I can read, that is just about maxed out on most machines. And I did awake several times during the study from the air pressure just about blowing the mask off my face.

Is this common to start out so high? And if so, how have you gotten along? An any tips that you can share with me.

I seem to be getting more tired by the day. - Thanks, and glad I found the site. I'm reading all I can get my hands on.

[Wulfman]

Welcome to the forum.
Keep reading.
At that pressure, you should be on a Bi-Level/Bi-PAP machine......and any sleep doctor who would prescribe that pressure without considering a Bi-PAP is "questionable" in my opinion.

However, I was also initially prescribed a pressure of 18 cm. on CPAP.......but, by purchasing a data-capable (CPAP) machine (in my profile) and the software, I was able to determine that pressures in the 10 to 12 cm. range were quite sufficient to treat me.
Much of it depends on the person and what was found in your sleep study (BE SURE TO GET A COPY OF YOUR SLEEP STUDY AND PRESCRIPTION).
I'm not saying that everybody who is prescribed higher pressure can use lower pressures, but there are many members of the forum who have reported that their sleep studies were not totally accurate......BOTH ways......some who were prescribed lower pressures actually found that they needed more pressure to provide better therapy.


Den

[Chris61]

What type of machine did you get? I have the Remstar Auto M Series and it has an auto ramp up which starts out at a lower pressure and goes up to where you need to be. I would also make sure that it records your data and then go back to your doctor with the stuff and talk about it and see if you need a change. I had mine at a high setting and was having problems and went to the doctor and he had it reset to the lowest setting. Keep in mind every one is differant. What part of Ind. are you in? If you have any questions just ask or e-mail me. I can say that part of my sleep apnea was do to weight and since I lost about 75 lbs my numbers are more normal. I also had a hard time adjusting to the machine and was able to go with a dental device and that works as well or better than the machine for me.

Chris

[BeanMeScot]

Your prescribed pressure has nothing to do with the severity of your apnea or starting out on CPAP. It is simply what is necessary to keep your airway open. At that pressure you should get a BiPAP as 20 is the max on a regular CPAP/APAP. You will definately need some type of exhalation relief as well. It would be next to impossible to breath out against that kind of pressure. A BiPAP will give you that, as well.

[bonjour]

Your prescribed pressure has nothing to do with the severity of your apnea or starting out on CPAP. It is simply what is necessary to keep your airway open. At that pressure you should get a BiPAP as 20 is the max on a regular CPAP/APAP. You will definately need some type of exhalation relief as well. It would be next to impossible to breath out against that kind of pressure. A BiPAP will give you that, as well.

For the record I have no problem of any kind exhaling at 19/20cm without pressure relief. In fact I prefer not to use a ramp to get up to this pressure.

I will agree that many users feel the need to have pressure relief, I think the max relief you can get short of BiPAP is 3 cm. And BiPAP is not just for high pressure users.

I do recommend getting a fully data capable model including the ability to determine various events.

My Mirage Aptiva nasal mask is (so far) the best mask I have seen for high pressure use. With most masks, both nasal and full face, I have to crank the straps down real hard to stop leaks. With the aptiva I adjust the mask to actually sit just off my face (no pressure) When the xPAP fires up the blower pressure actually expands the mask sealing it to your face with minimal force.

Fred

[DoriC]

Den, Other than some techs just being inept at their jobs, what could account for such a disparity between a titration study and auto-titration at home? Just what do they look for during the study and what methods do they use to arrive at the "right pressure"? Do they keep trying to eliminate all snores, leaks, limb movements,etc.?

[rubymom]

I'm pretty new at this too--about 6 weeks or so. My pressure was also prescribed at 20. I felt like the machine was blowing a tornado at my face. I could not tolerate it. I would use the ramp feature and fall asleep nicely but as soon as the pressure went up, it would wake me up. I was told I needed to "fail" at the CPAP which I did and then I was allowed to get a Bi-pap machine. Wow, what a difference!! I'm still trying to get past the point where I take the mask off in my sleep (usually I think it's because some leaks develop and mild fiddling with it doesn't work so I just rip it off). But I've had a few nights where I went all night long with it.

I don't have the fancy software (yet) but it looks like I'm averaging a pressure of about 12-13 on the Bi-pap. I like it alot and think that this will be good for me for the long run.

Talk to your DME and/or your doctor about trying something different.

Good luck!!

[dsm]

Sleepless in Indiana,

As Wulfman has said - you need the doc to prescribe a bilevel (Bipap or Vpap). At 20 CMs you are being asked to take on one hell of a therapy burden if expected to do it with a staright cpap.

The mask management will be your greatest challenege but this is *greatly* helped if you get a bilevel. But, one warning re this, to be really fair you need a bilevel titration as there are cases where someone set to 20 CMs needs careful evaluation of what to set the lower pressure to.

Also, (& this is a sensitive area), are you significantly overweight ? - if yes then there is always going to be a struggle going on between the weight, the OSA destroying ones health & the ability to tolerate the therapy at a setting so high. Weight reduction is essential.

Whatever the challenges, you have come to the right place to ask for help because people here have been through it all.

Good luck & keep asking

DSM

[Wulfman]

Den, Other than some techs just being inept at their jobs, what could account for such a disparity between a titration study and auto-titration at home? Just what do they look for during the study and what methods do they use to arrive at the "right pressure"? Do they keep trying to eliminate all snores, leaks, limb movements,etc.?

Dori,

In my case, I believe it was the snores that they were trying to eliminate. They actually stopped titrating at 16 cm., but noted some residual events.....so, the doctor added two more cms. to that. I DID try 18 for about an hour and although I was able to get some sleep, I felt it was way too high to start with......so, I used some logic and started with 10, monitored it with software and stayed with that for nearly a year. I had an average AHI of 1.0 or less (early on), but the snoring was still "significant" so I finally started experimenting with nasal cleansing and a little more pressure and 12 was what I settled on. My experiments with an Auto (range of pressures was 10 - 15) for a week in July of 2006 verified that 12 was about right, too. (I only reached 15 for about 1 1/2 min. on only one night)


Den

[dsm]

Den, Other than some techs just being inept at their jobs, what could account for such a disparity between a titration study and auto-titration at home? Just what do they look for during the study and what methods do they use to arrive at the "right pressure"? Do they keep trying to eliminate all snores, leaks, limb movements,etc.?

DoriC, I know you asked Den but pls allow me to add 0.2 c worth. The sleep clinics do vary depending upon their own agenda. We have seen here how one sleep clinic owner/director (DR Krackow), believed it essential to tune the therapy right up to the flow limitations whereas most clinics go fo apneas & hypopneas. I believe the majority of clinics are interested in what meets insurance criteria. I am sure Muffy (aka lots of other aliases) will have his own POV that may be unique.

But the reality is, the sleep clinics don't always titrate to the same purpose & most are under the influence of a director who does have his targets & agendas be they running a state-of-the-art clinic, supporting research, focusing on CHF patients, or just meeting the requirements of the health insurance industry. My belief is the latter is the dominant basis on which the majority operate.

DSM

[Hawthorne]

A disparity between a sleep lab titration and an "in home" auto titration may have nothing or not much to do with the competence of the technician.

It could be that, but it could also be a result of that very unusual sleeping situation. A person is all wired up and is experiencing sleeping with a mask and a machine for the first time (unless it's a retitration). The room temperature, the bed, the request for back sleeping (in most cases) and just the general surroudings in a sleep lab could account for that disparity.

Also, the fact that is is based on only 1 night of less than ideal sleeping, could make a great difference.

I just recently got my sleep study results (all 3 of them - diagnosis sleep, first titration - from 2002 and re-titration - 6 years later). I slept just barely over 4 hours for each of them!! That's barely enough to get reliable data. At home, I sleep about 6 1/2 to 7 hours so the data is more reliable.

I think a sleep study in a sleep lab is very important, at least for initial diagnosis or if some other sleep disorder may be suspected, since so many other things are monitored but other that, in my opinion, at home with an auto is more reliable for setting or adjusting pressure.

[DoriC]

So I guess what I'm asking, what is the consensus of how many wind up with the same pressure as was titrated during the study or do they usually end up testing with a range of pressures on auto at home and settle on a completely different cpap pressure than was prescribed. Is that confusing? I'm interested because I've always had a "thing" about getting hubby's pressure as low as possible and so I'm always experimenting down from his titrated pressure of 13 sometimes with frustrating results. He never did well on 13, discomfort, too many leaks, restlessness, and incidentally, more snores? And pressure changes even at narrow ranges bothered him as well. So we ended up at 12 (after much negotiating), and he does well, but here I am again experimenting again the last week at 11-12.5 and he's sleeping 75-80% of an 8-9hr night at 11 with good AHIs of 0.6-1.2, snores a little higher. I know 12 is probably where he'll do the best but that little devil makes me want to try pressure at 11. Is a lower pressure sometimes sufficient once one is compliant and adjusted well to the therapy. I think I'm one of those people who would have been better off with a non-auto cpap machine. Thanks and get out the 2x4 if you think I need it! Dori

[Hawthorne]

I didn't know enough about sleep apnea after my diagnosis and titration study to know that my titrated pressure may be off for a variety of reasons.

It took me 6 years using a straight cpap with no data and a better education on this forum, to begin wondering and wanting to see if things could be better!

I bought an auto on my own with the software and, with a lot of help from forum members, I got a good setup going --for me. Then I FINALLY had my retitration. I had started "the wheels rolling" for the retitration (because I was feeling more tired that I had been during the day) in October of 2007, bought my own auto in February of 2008 and got it set up with lots of help (Thanks!) and was doing well. I had my retitration in April 2008 even though I was doing much better. I wanted to see if anything else was going on. As I said, I again slept just over 4 hours in the sleep lab and they could only get my AHI to 4.2 with a pressure of 9 cm (1cm below the setting for the 6 years prior!). I was, and am still getting AHI below 1 most nights with the setup on my auto (range 10.5 to 13 cm - 90% pressure 12 cm) at home.

Dori - I too want the lowest pressure possible for me but, more than that -I want whatever pressure is going to keep my airway open enough so that I get the best therapy possible. Like you, I will probably continue to experiment every once in a while!

[DoriC]

Hawthorne ,OK, I can see how you got to this point in your therapy, but I have another question. Based on your current settings, if you were going to go with straight cpap, which pressure would you use, 10.5 11, 12 or 13 and why? Although I know it's an individual thing, It would be helpful to know that so I can rationalize for myself Mike's best cpap pressure. You know with me it's never easy! Thanks, Dori

[Hawthorne]

I would set my straight cpap pressure at 11.5 cm probably because, while my 90% is 12 cm, my Average cpap pressure on my auto settings is between 11 cm and 11.4 cm.

I actually have an M Series Pro for backup and travel set at 11.5 cm. I set it based on that Average cpap pressure. According to my "Daily Events per hour" at the bottom of page 4 of my reports, I spend a very large part of the night at 11 cm. I spend a little time at 12 and, only on the odd night do I go to 13cm and for a very short time when I do. My nights are almost always the same, give or take the odd slightly different night now and then.

I don't know if that's logical or not! That's how my backup is set and why. That is then, what I would set my machine at if I had it on straight cpap mode.

Hope that helps!