VPAP Auto pressure- need advice- Update

[magentapolkadots]

I need guidance on what to do with my pressure to get better results.

During my 2 week trial w/ the Auto 25, I felt wonderful-- very rested. Since coming home w/ my own machine, things haven't gone so well. During the trial period the settings/ summary results were:
Max IPAP- 16.0 Min EPAP- 6.0 Pressure Support: 4.0
Pressure: Median- 11.8 95th%- 14.4 Max- 16.0
Leak: Median- 0 95th%- 1.2
AI- 3.4 AHI- 11.8 % time in apnea- 1.4

Currently my machine is running in auto mode (to smooth the transitions between IPAP/EPAP) but pressure settings are:
Max IPAP- 13.0 Min EPAP- 9.0 Pressure Support 4.0
...so there isn't any adjusting going on.
2 week avg is AI- 3.9 AHI-15.4
I'm also having considerable leak issues recently. I have replaced my Quatro seal in hopes that my leak issues will improve.
My thoughts are that the Max IPAP needs to be increased to at least 14.4 -- where my 95% was during the trial. But I understand that too high of a pressure can cause central apneas? I'd like to be informed in any changes I make, so would greatly appreciate advice.

Also-- for those who may have read another recent thread/query of mine, I have not yet started back on my nightly dose of diazepam for fibromyalgia. So that would not be a cause for increased apneas.

I have only just yesterday received my card reader, so have one day's chart to share.






Many thanks to Pugsy and dlp for helping me get my charts posted. Thank you , thank you, thank you!!!
Kim

[jnk]

Why is Max IPAP at 13? Did the doc do that? Was your sleep study diagnosis strictly obstructive sleep apnea? What was your Rx? Have you had trouble with centrals? If those are obstructions, it sure would be nice to get rid of more of them. A higher Max IPAP would allow the EPAP to get higher to prevent more of those apneas if they are obstructive. Especially if you have health issues beyond OSA, though, it is good for your sleep doc to be on board with the idea of your tweaking, in my opinion.

[magentapolkadots]

Why is Max IPAP at 13? Did the doc do that?

Yes, the doc did that. I started on straight CPAP at 13, but was switched to bilevel after 3 weeks of horrible aerophagia. Not sure why he chose 13/9 after the 2 week bi-level trial. I didn't ask at the time- not knowing enough to know what to ask.

Was your sleep study diagnosis strictly obstructive sleep apnea? What was your Rx?

Yes, strictly OSA, no centrals. Also, many periodic limb movements (confirmation of long suspected RLS) Titration was w/ straight CPAP. Original Rx CPAP 13, changed to VPAP 13/9 PS 4.

Have you had trouble with centrals?

Only one central in first study (the one that diagnosed the OSA. No centrals during titration study,

A higher Max IPAP would allow the EPAP to get higher to prevent more of those apneas if they are obstructive.

I was thinking that as well, but not sure how much to bump up (14, 15 16?)

Especially if you have health issues beyond OSA, though, it is good for your sleep doc to be on board with the idea of your tweaking, in my opinion.

Only other health issues are fibromyalgia & restless leg syndrom- RLS currently untreated, wanted to see if it still kept me up once the OSA was addressed. Discontinued one fibro med at sleep docs suggestion (valium at bedtime). I want to add it back due to pain issues, but am waiting to discuss w/ him at my appointment on the 22nd. Was trying to wait till then to address pressure issue, but I am SO tired and SO achey. Thus seeking advice here.

Titration study stated "sleep was consolidated at 13cm." "sleep fragmentation increased at pressures above 13cm."

Thanks for the questions, jnk. I still don't know enough to know what is important to include. Any further thoughts?
Kim

[jnk]

From your answers, I would guess maybe the doc capped your IPAP where he did in order to be absolutely sure to prevent aerophagia. He may be planning to look at your data and ask you about aerophagia and adjust from there, since it may be a balancing act for you to get the fewest events with the least amount of aerophagia.

But, yeah, if it was me, and I had been diagnosed with OSA with no complicating factors (other than the aerophagia), I would probably raise my Max IPAP a cm or two to allow the auto to do some auto-ing. I would try not to offend the doc that was going out of his way to help me, though, so I would keep the doc in the loop with any changes I made, just as a patient-to-professional courtesy. A simple phone call should do.

[magentapolkadots]

Thank you again, jnk.

My doctor doesn't yet know that I have tweaking capability, so the courtesy call is a very good suggestion.

[jnk]

Thank you again, jnk.

My doctor doesn't yet know that I have tweaking capability, so the courtesy call is a very good suggestion.

One way is to make a "confession" call after sleeping one night with it a cm or two higher. (Sometimes it is easier to get forgiveness than permission. ) But you know your doc best. Sometimes combining the notification with a thank-you works. Or you could simply leave a message with the receptionist about what you did and say the doc can call you back if he thinks it is necessary, but that you aren't asking him too--you are just keeping him informed.

Or you can just do it. It is after all, YOUR health. Some docs get their feelings hurt sometimes. That's all. And I was just saying what I would do.

Hope it turns out well for you. Sounds like you are well on your way.

And you are very welcome.

Keep us informed. That's even more important than keeping the doc informed, since your posting what happens here is a way that your experience helps countless others.

jeff

[twokatmew]

Although my DME's RT had a fit when she saw I'd changed my pressure, my doc wasn't bothered at all. He seemed glad I'd done a bunch of troubleshooting before I saw him, as it made it easier for him to decide what to try next. He's been my pulmonologist a lot longer than he's been my sleep doc though, so he's used to me being proactive in my asthma treatment.

[magentapolkadots]

Well, I did it. I upped my own pressure without official permission. Being a natural born rule-follower, I felt guilty at the time. Now I feel justified, as there was some improvement.

Previous settings: max IPAP 13, min EPAP 9, PS 4.
Previous results: AHI 15.2 AI 3.9

New settings: max IPAP 14.4, min EPAP 9, PS 4.
New results: AHI 9.7 AI 3.2
Pressure: median- 13
95%- 14
max- 14.4
While the AI reduction from 3.9 to 3.2 doesn't seem like much, I felt more rested this morning.

Official results look like this...



Thank you again jnk. I needed someone who knows this stuff better than me to help me figure out if my inclination was on target. You gave this rule-follower the confidence to make an informed decision. I left a message for the doc today, didn't hear anything back. Guess that means I won't be grounded. Hopefully this will give us some good information to move forward with when I see him next Tuesday.
-K

[jnk]

I'm glad if my words, about what I would likely do if it was me, turned out to be of some use to you, but I have a long way to go before I know any of "this stuff." I am actually a bit of a rule-follower myself (despite what carbonman may say about me ). And your doc may have a gameplan we don't know about, although I can't figure out what it could be.

So, no aerophagia last night? Because it looks like I would still raise my Max IPAP to allow that EPAP high enough to put a dent in those half-minute apneas, if the only risk I was running was aerophagia.

Did your sleep study say anything about positional apnea in supine? If so, your rigging up something to stay off your back might help too.

[magentapolkadots]

No aerophagia at all!

I'm all side sleeper, all the time. Both my sleep study & my titration commented that they didn't get as much supine sleeping as they would have liked. I just can't sleep on my back. So all those apneas are on my side.

I did think about pushing it a little higher-- to the Max 16 my doc had me at during the 2 week VPAP trial. I guess 14.4 seemed like a smaller crime. I picked that number b/c it was my 95% during the 2 weeks. Will think about 16 between now and bedtime, am already thinking it sounds like a good idea:)
-K

[jnk]

Well, if I was already a criminal , and was gonna raise my max to 16, I'd probably take my Min EPAP on up to 10 for good measure. What would I have to lose?

(I will, of course, deny our ever having this conversation.)

[timbalionguy]

No aerophagia at all!

I'm all side sleeper, all the time. Both my sleep study & my titration commented that they didn't get as much supine sleeping as they would have liked. I just can't sleep on my back. So all those apneas are on my side.

I did think about pushing it a little higher-- to the Max 16 my doc had me at during the 2 week VPAP trial. I guess 14.4 seemed like a smaller crime. I picked that number b/c it was my 95% during the 2 weeks. Will think about 16 between now and bedtime, am already thinking it sounds like a good idea:)
-K

You may want to stay at this pressure for a few days to a week, to get a bigger picture of the effectiveness of the change. In general, I think most here would agree that gradual is better.

[carbonman]

Well, if I was already a criminal , and was gonna raise my max to 16, I'd probably take my Min EPAP on up to 10 for good measure. What would I have to lose?

I am actually a bit of a rule-follower myself (despite what carbonman may say about me ).
too.

....ahhh...you Vpap guys think you're so smart.....
with all those special pressures and fancy settings on those machines.....

...what a bunch of show offs......

.......you haven't followed any rules since you promised you were going to be on YOUR best behavior.......

...hey, I can figure stuff out too.....I'm breaking rules every night.....

....don't every kid yourself.....I rule that ramp button....it knows who the boss is...

....and I preheat that HH when I'm good and ready......

.....yea....you're not the only rule breaker out there.....
I may just be an apap guy.....I'm in control.....oh, yea.....
....sometimes I change my max pressure.....just BECAUSE I CAN!

....and don't you every forget it.

[jnk]

. . . You may want to stay at this pressure for a few days to a week, to get a bigger picture of the effectiveness of the change. In general, I think most here would agree that gradual is better. . . .

I agree. Gradual is always better when tweaking when starting out at a pressure that a PSG has found to be effective.

But after dropping pressure way down below effective levels to avoid aerophagia, I would want to get EPAP back up to where it is doing something as soon as possible, before I slowed down to tweaking speed, if it was me. I would tend to view it as returning to an effective pressure, and, in my opinion, changing a range in an auto is a little different from changing a treatment pressure outright.

That being said, I very much agree that the usual problem with us changing our own pressures, or range of pressures, is that we tend to be impatient and to make too many changes too quickly, so I personally appreciate that reminder, timbalionguy.

[magentapolkadots]

Well, I did up the IPAP just a bit to 15 and what a difference!
AHI- 7.8 AI- 1.3
I felt so much more rested this morning. Didn't have any aerophagia, just one big burp when I rolled over to hit the snooze button

I'm going to leave it there and gather some data between now and when I see the doc next week- see if further adjustments are necessary after discussing it with him.
Thanks again to all on this board who take the time to read and respond,
-K