Which Therapy Is Better?

[Komodo]

A month ago I switched from a Cpap to a Vpap auto.The initial settings were IP: 22cmH2O, EP: 18cmH2O. Without even trying it at that level, I dropped it down to 20/16. When I checked my data the following day, that gave me a straight line pressure of 18cm on the graph. I kept it there for a week, then dropped it again to 18/14. That data gave me a straight line pressure of 16cm. Once again, I dropped the pressure to 16/12. That resulted in a "true graph" of pressure readings. The pressure went up and down from 14cm to 14.9cm.
My AI is the same in all pressures
My HI is slightly higher with the lowest pressure

My feelings are, that the lower the pressure, the better it is for you overall in the long run. If you don't NEED the high pressure 100% of the time, why have it? I'd rather be breathing on my own (so to speak) until I needed that "boost" of pressure from the machine.

So......What are your opinions???

Keep a "true graph" pressure setting?

Go back to a "straight line" graph?

Stop asking stupid questions?

[Slinky]

There is another setting: the Pressure Support. Your PS is set at 4 (22/18, 20/16, 18/14, etc.) The "straight" pressure line is the midpoint pressure, i.e. 1/2 of 4 is 2.

When you dropped the settings to 16/12 and started getting 14 to 14.9 on the graph, it was because there were times during the night you needed a higher than 12 EPAP.

I think I explained that right. jnk can 'splain it better, I'm sure.

How was your reported Leak the night(s) of the reported 14 - 14.9 pressure?

[Big Daddy RRT,RPSGT]

I generally agree that the lowest "effective" pressure is the best because it fosters compliance.However the best therapy is the one that minimizes respiratory events, eliminates significant oxygen desaturation and minimizes sleep disruption and includes un-disrupted supine REM. Some people sleep and feel better on a static pressure, others sleep and feel better on an appropriately set dynamic pressure. But there are other considerations...

Having a full copy of your baseline sleep study and your titration would be very helpful. The main question is why did they select such a high pressure, was it needed to prevent oxygen desaturation? Was it needed to "push" you into REM. We see this sometimes in the sleep lab, the AHI is very low but the patient doesn't have REM, you go up in pressure and "push" some REM, an auto won't do that. An auto is designed to treat respiratory events, snoring, apneas, flow limitations etc. It won't titrate for these other conditions.

Request full copies of your sleep reports, not just the dictations. With careful deciphering you can see why they went so high. It's always possible you were over titrated or you only needed the additional pressure while supine or during REM. If this is the case you might set use the higher pressure that you needed during these times as your max and then use the lower pressure that you slept well on otherwise as your lower pressure.

If pressure toleration is a problem set a lower ramp pressure to start out the night but know that you will probably have more respiratory events during the ramp time and any time you need more pressure (on your back or during REM) you will have respiatory events (which might include sleep disruption or oxygen desats) until the auto reaches the required pressure. This is good sleep lost but may be worth it if overall it increases your compliance or your overall response to therapy is better than a static or very limited auto range.

If significant oxygen desaturation is a problem in your sleep reports you could find your "best" pressure settings and then request an overnight pulse oximetry to check your oxygen level. Be especially careful if your have heart disease as messing with your pressure can have detrimental/dangerous effects.

I hope this helps your understanding, Good luck.

[mars]

Hi Komodo

Without understanding all the in's and out's of bipap machines, I have had similar experiences with different cpap and apap settings.

But so far I have never had an answer to the query which I think is most relevant to this, so I repeat the query in the hope that perhaps - Big Daddy RRT,RPSGT, or someone else, can now help on this.

From a previous post -

I have found that I can use about a dozen different settings, and still get between 2.0 and 2.4 Obs/Cnt AHi on all of them. What would be a significant difference? e.g. 0.1 or perhaps 0.4?

In auto I have tried many different pressure ranges, variations within a range of from 10.0 to 13.5, and also different cpap settings - 11, 11.5, 12.0.

Over an average of 10 days in each setting, I get an Obs/Cnt AHi of between 2.0 and 2.4, which includes Sandman centrals.

Is there a measurement - 0.1, 0.2, 0.3 or 0.4 or perhaps even more, where the difference becomes significant in terms of general well-being in regard to the therapy. On a personal level I cannot tell a difference.

It's kind of like the cutoff safe AHi of 5.0, would there be a legitimate need to do something if the AHi was 6, or 7, or 8, etc, or would those few points be insignificant. Where did the wisdom come from that it was safe to have 5 events an hour?

I asked a similar question in December 2009 and February 2010, and now I have even more months data, which still supports many different range settings = same result (more or less).

I "think" this is relevant to your thread, Komodo, maybe Big Daddy RRT,RPSGT can help out there.

cheers

Mars

[Komodo]

I generally agree that the lowest "effective" pressure is the best because it fosters compliance.However the best therapy is the one that minimizes respiratory events, eliminates significant oxygen desaturation and minimizes sleep disruption and includes un-disrupted supine REM. Some people sleep and feel better on a static pressure, others sleep and feel better on an appropriately set dynamic pressure. But there are other considerations...

Having a full copy of your baseline sleep study and your titration would be very helpful. The main question is why did they select such a high pressure, was it needed to prevent oxygen desaturation? Was it needed to "push" you into REM. We see this sometimes in the sleep lab, the AHI is very low but the patient doesn't have REM, you go up in pressure and "push" some REM, an auto won't do that. An auto is designed to treat respiratory events, snoring, apneas, flow limitations etc. It won't titrate for these other conditions.

Request full copies of your sleep reports, not just the dictations. With careful deciphering you can see why they went so high. It's always possible you were over titrated or you only needed the additional pressure while supine or during REM. If this is the case you might set use the higher pressure that you needed during these times as your max and then use the lower pressure that you slept well on otherwise as your lower pressure.

If pressure toleration is a problem set a lower ramp pressure to start out the night but know that you will probably have more respiratory events during the ramp time and any time you need more pressure (on your back or during REM) you will have respiatory events (which might include sleep disruption or oxygen desats) until the auto reaches the required pressure. This is good sleep lost but may be worth it if overall it increases your compliance or your overall response to therapy is better than a static or very limited auto range.

If significant oxygen desaturation is a problem in your sleep reports you could find your "best" pressure settings and then request an overnight pulse oximetry to check your oxygen level. Be especially careful if your have heart disease as messing with your pressure can have detrimental/dangerous effects.

I hope this helps your understanding, Good luck.

Thank’s for that reply.
In my case, I’ve been 100% compliant since day one, never used the ramp feature because I’ve never had a problem with the pressure. I have copies of all my sleep studies and have gone over them with a fine tooth comb. In my opinion, I was GROSSLY over-titrated! To the best of my knowledge, oxygen desaturation has never been an issue. I have no problem getting REM sleep with the lower pressures, sleep undisturbed all night, and wake up fully rested.
Another advantage for me is, lower leak rates, which give me more effective therapy.

At my lower pressure settings, I stay at 14cm for 95% of the night, with only a very few “spikes” of less than 1cm. At 16cm, there are no “spikes”, but also, there is no change in my overall AHI.

It’s apparent that I need that extra 1cm of pressure 5% of the night, but is the extra 2cm the other 95% of the night doing me more harm than good? I have COPD and my lungs are in bad shape to start with. I don’t want my body to get used to, and depend on, the added support of a machine in order to breathe. I know that’s a question for my doctor, and YES, I will be asking him latter this week when I see him. I just like to get the opinions from fellow Forum members before I go to see him.
You guys know more than he does!

[Komodo]

There is another setting: the Pressure Support. Your PS is set at 4 (22/18, 20/16, 18/14, etc.) The "straight" pressure line is the midpoint pressure, i.e. 1/2 of 4 is 2.

When you dropped the settings to 16/12 and started getting 14 to 14.9 on the graph, it was because there were times during the night you needed a higher than 12 EPAP.

I think I explained that right. jnk can 'splain it better, I'm sure.

How was your reported Leak the night(s) of the reported 14 - 14.9 pressure?

You explained it just fine

My leak rates go down, the lower the pressure

[Komodo]

I "think" this is relevant to your thread, Komodo, maybe Big Daddy RRT,RPSGT can help out there.

cheers

Mars

Yeah, I think we're both pretty much talking about the same thing. It's kinda like if you have a headache, what should you take, and asprin or a shot of morphine? Both will get rid of the pain, but do you really NEED the morphine???

[echo]

Having a full copy of your baseline sleep study and your titration would be very helpful. The main question is why did they select such a high pressure, was it needed to prevent oxygen desaturation? Was it needed to "push" you into REM. We see this sometimes in the sleep lab, the AHI is very low but the patient doesn't have REM, you go up in pressure and "push" some REM, an auto won't do that. An auto is designed to treat respiratory events, snoring, apneas, flow limitations etc. It won't titrate for these other conditions.

Big daddy, can you go into some more detail on this? Reason I ask is that:
- I was titrated with an Auto, not manual titration. REM was only 7% during the titration (down from 12% during PSG). My 'titration pressure' was somewhere between 7-10, ideally 10 but then I was supposedly getting too many central's so I should start at 7 and see how i feel (that's the literal phrase from my sleep doc)
- I started at 7cm straight CPAP in 2007
- I eventually self-titrated to 10.5cm straight CPAP after a few months (no significant CA's in the 2+ years on this pressure)
- My AHI is the same at 7cm as at 10.5 cm... but I sleep MUCH better at 10.5cm. I thought it might be related to the reduction in "flow limitation runs" but now I'm wondering if it also has to do with REM sleep.

What is the mechanism by which a lower pressure gives the same AHI as a higher pressure, but the higher pressure "pushes" you into REM sleep?

I've noticed this referrence in other titration posts too.

[Big Daddy RRT,RPSGT]

Echo,
As to why more pressure can "push" REM. The reason is not clear and even controversial...for example if left on a lower pressure would you have REM anyway without the pressure push? I call it technolgist intuition. Will more pressure cause more arousals, or less. Well usually more arousals if it's un-needed, less arousals if it fixes an unrecognized flow limitation. In fact that's what I think you pay for with a Sleep Lab titration...trial and error. That's why a CPAP titration study isn't usually described as a good sleep as we keep messing with the pressure trying to find the "sleep zone".
Big Daddy RRT,RPSGT

[Big Daddy RRT,RPSGT]

Mars,
I have found that I can use about a dozen different settings, and still get between 2.0 and 2.4 Obs/Cnt AHi on all of them. What would be a significant difference? e.g. 0.1 or perhaps 0.4? In general none, unless you feel/sleep better.

In auto I have tried many different pressure ranges, variations within a range of from 10.0 to 13.5, and also different cpap settings - 11, 11.5, 12.0. Over an average of 10 days in each setting, I get an Obs/Cnt AHi of between 2.0 and 2.4, which includes Sandman centrals.

Is there a measurement - 0.1, 0.2, 0.3 or 0.4 or perhaps even more, where the difference becomes significant in terms of general well-being in regard to the therapy? On a personal level I cannot tell a difference. No not in general, if your oxygen level is good, your AHI is <5 and your Arousal index is less than 10 then your cured! Of course it doesn't always work that way, subtle changes can make a difference but where did you start....An AHI of 100...an AHIof 5 on CPAP is awsome...An AHI of 8...an AHI of 5 on CPAP sucks. If you can't tell the difference, the lowest setting is the easiest to tolerate for most people. without a sleep study on this setting you have no idea how your oxygen varies or your sleep quality varies, but how you feel is a pretty good indicator but it may not reflect your oxygen desaturations.

It's kind of like the cutoff safe AHi of 5.0, would there be a legitimate need to do something if the AHi was 6, or 7, or 8, etc, or would those few points be insignificant. Where did the wisdom come from that it was safe to have 5 events an hour? You test normal weight people who don't snore and don't report symptoms of OSA...just about everyone has some hypopneas. So in general people with AHIs less than 5 rarely complain of symptoms of OSA and don't end up requesting sleep studies (UARS being an exception.) Even at an AHI of 5 we have a hard time improving daytime sleepiness with CPAP. You really trade one disruption (mild OSA) for the disruption of CPAP (mask,hose, air pressure). The mild group is really hard to find success with treatment.



I asked a similar question in December 2009 and February 2010, and now I have even more months data, which still supports many different range settings = same result (more or less).

[Big Daddy RRT,RPSGT]

Komodo,
In my case, I’ve been 100% compliant since day one, never used the ramp feature because I’ve never had a problem with the pressure. I have copies of all my sleep studies and have gone over them with a fine tooth comb. In my opinion, I was GROSSLY over-titrated! To the best of my knowledge, oxygen desaturation has never been an issue. I have no problem getting REM sleep with the lower pressures, sleep undisturbed all night, and wake up fully rested.
Another advantage for me is, lower leak rates, which give me more effective therapy.This sounds like solid reasoning for the lower pressure, but your Dr ain't gonna like that you've "messed" with your machine especially with COPD. Bad lungs, OSA and no oxygen problems? This is a surprise but good. Your Dr may want an overnight pulse oximetry to make sure.

At my lower pressure settings, I stay at 14cm for 95% of the night, with only a very few “spikes” of less than 1cm. At 16cm, there are no “spikes”, but also, there is no change in my overall AHI.It’s apparent that I need that extra 1cm of pressure 5% of the night, but is the extra 2cm the other 95% of the night doing me more harm than good? No harm but maybe good, this may be preventing respiratory events during REM. You can try setting it at your 95th pressure and eliminating the Auto and see if you feel even better. Some people prefer a static set pressure, many prefer the auto's dynamic pressure.

I have COPD and my lungs are in bad shape to start with. I don’t want my body to get used to, and depend on, the added support of a machine in order to breathe. I know that’s a question for my doctor, and YES, I will be asking him latter this week when I see him. I just like to get the opinions from fellow Forum members before I go to see him.
There doesn't seem to be evidence of COPDers getting weak or dependent from using pap therapy in fact the opposite is true. COPDers benefit from appropriate pap therapy. As for being "overtitrated", a COPDer, might be "over-ventilating" and this can have an effect on respiratory drive. That's why a Sleep Lab titration is important for people with other medical conditions like heart and lung problems. Did they use an End Tidal CO2 monitor during your titration? Most labs do not, but some advanced labs might for a person with "bad lungs". This might explain the higher pressure titration. (You needed higher pressure in response to a CO2 problem.) People with lung disease can have these issues. Something to ask about.

[Slinky]

BigDaddy, would you please explain an "End Tidal CO2 monitor"???

I have COPD and we've been diddling around for 3 1/2 years w/o finding the correct pressure settings for me. I was started on straight CPAP in Oct 2006. I've been 100% compliant since then. They diddled and farted around for 17 months before switching me to a bi-level in March 2008. And they've been diddling around ever since. It is ridiculous that someone who has been 100% compliant for 3 1/2 years still has to wait 6 weeks between pressure changes.

Of course, it is not their fault that I didn't sleep for beans or enough to get a proper titration this past January. I didn't expect that so never thought to bring an Ambien just in case. I've slept 5 1/2 - 6 hours at previous titrations.

On the other hand, they ignored my questioning my reported leak rate for months and months. And like I said it is ridiculous that someone who has been 100% compliant for 3 1/2 years still has to wait 6 weeks between pressure changes or consults. As of my last ABG I was still not a C02 retainer.

[mars]

If you can't tell the difference, the lowest setting is the easiest to tolerate for most people. without a sleep study on this setting you have no idea how your oxygen varies or your sleep quality varies, but how you feel is a pretty good indicator but it may not reflect your oxygen desaturations.[

Hi Big Daddy

(Sorry, but I cannot help thinking of Burl Ives in "Cat On A Hot Tin Roof" whenever I see your forum name. So some neural pathways are still working, but not always the one's I need.

Thank you for clarifying those queries for me. I kinda figured there was a robustness about the xpap treatment which allowed some leeway in pressure settings. I have used my oximeter on the different setting, and never gone into desaturation, even though there have been clusters of events. (Never been able to get a definition of clusters either).

So I will rest easy about this, still experimenting at times, but generally keeping to my 11.0 to 13.0cmH2O range.

cheers

Mars

[Big Daddy RRT,RPSGT]

BigDaddy, would you please explain an "End Tidal CO2 monitor"???

I have COPD and we've been diddling around for 3 1/2 years w/o finding the correct pressure settings for me. I was started on straight CPAP in Oct 2006. I've been 100% compliant since then. They diddled and farted around for 17 months before switching me to a bi-level in March 2008. And they've been diddling around ever since. It is ridiculous that someone who has been 100% compliant for 3 1/2 years still has to wait 6 weeks between pressure changes.

Of course, it is not their fault that I didn't sleep for beans or enough to get a proper titration this past January. I didn't expect that so never thought to bring an Ambien just in case. I've slept 5 1/2 - 6 hours at previous titrations.

On the other hand, they ignored my questioning my reported leak rate for months and months. And like I said it is ridiculous that someone who has been 100% compliant for 3 1/2 years still has to wait 6 weeks between pressure changes or consults. As of my last ABG I was still not a C02 retainer.

It's good you are not a CO2 retainer. This is an indicator of your lung function. It does not necessarily reflect your CO2 level while you are sleeping especially if you have borderline lung function. For example good blood gases at rest...but you can't walk down the street because your too short of breath. So good resting ABGs but what about during exercise or during sleep....very different.

What have they been trying to fix with all the changes?

An End tital CO2 monitors the amount of carbon dioxide in your exhaled breath and is a reflection of the amount of CO2 in your blood. People with lung disease can have difficulty exhaling CO2. Obese people may have hypoventilation syndrome causing a build up of CO2. There are other diseases that can cause similar problems. Like I said you don't see them used very much but sometimes in the more advanced sleep labs. It is a more common item in surgical recovery or the ICU but you do see it in the sleep labs where they deal with very sick patients.

6 weeks between pressure changes? This is a government / insurance problem. Let me explain...The guy who does the test, can't provide or adjust the equipment, and the guy who provides/adjusts the equipment can't do the test. The doctor who orders/interprets everything can't do either. Therefore you have three separate groups handing one very complex problem to prevent conflicts of interest. In other words...I work in a sleep lab so I think everyone should have a sleep study...not really but you get the idea. It's supposed to prevent unnecessasry use of testing and equipment. The reality is it really slows down the process. Good Luck. I hope this helps your understanding.

[Slinky]

Thank you. The last ABG was done after a six minute walk. We were supposed to do the draw w/in 20 seconds of finishing the six minute walk. But first try we hit a vein rather than an artery. The next draw we managed to get w/in 27 seconds of finishing the 6 minute walk. Since Spo02 by oximeter was 84% at the end of the walk and was still 84% when we accomplished the draw we decided it was good enough for the guys I go with (translate to doctor who ordered the test) and we never told anyone who mattered that it took us 27 seconds instead of 20.