Which Therapy Is Better?

[Big Daddy RRT,RPSGT]

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.

20-27seconds close enough. The pulse ox really told the oxygen story and your CO2 would be unlikely to recover in 27 seconds.

The kind of self titrations so many people do are probably not for you as you have a concurrent medical issue (COPD). You should wait on your doctor to approve changes with your PAP as you do de-saturate at least sometimes. Your lung disease can make the kind of changes many people make on their own risky for you. But it sounds like you do or you wouldn't be so frustrated. Hang in there, you do need your doctor to manage your pap therapy and COPD. I would say the same for people with heart disease. But educating yourself that's really important because you can known the right questions to ask and then know what it means.

[Slinky]

Well, I purchased my own recording oximeter as well as a Nonin Onyx for when I'm out and about. There's been NO CONTINUITY of care. My sleep lab has rotating sleep pulmos, 5 of them. All pleasant, soft-spoken, and due to inconsistent care, dang near useless as the t*ts on a boar hog. 17 months to decide to switch me to bi-level? 26 months and still not at effective pressures? Admittedly, some of the delay, especially since the bi-level, has been due to getting so frustrated and disgusted I just suffer along and don't call and insist on help. Its gotten so that when they say I'd like to see you again in three months I want to smack them! My one venture to another sleep lab and sleep doctor was an even worse experience. I've provided downloaded printouts of PAP data and oximetry data having bought the software in self-defense. and then I go and blow this last in-lab titration by not sleeping phershtunga and am stuck w/relying on the auto bi-level data for another year - well 8 months now. I even managed to get a loaner auto bi-level of another brand and the software for that and am getting no where so far.

[echo]

thanks for the explanation big daddy.

sorry you're not making any progress slinky I can imagine you REALLY want to push SOME people off some stairs, somewhere!!!

[Slinky]

How'd you guess, echo? The thought has occurred. I'm just very, very, discouraged. I try to console myself I'm sleeping better than before CPAP - but - I don't always believe myself. I've been going backward since the first of the year, I swear.

[Muse-Inc]

How'd you guess, echo? The thought has occurred. I'm just very, very, discouraged. I try to console myself I'm sleeping better than before CPAP - but - I don't always believe myself. I've been going backward since the first of the year, I swear.

Ah Slinky, you don't post like that's so. But I know the feeling. These dratted multiple nightly wakeups suck and I'm tired & crabby. I lost 57#s and now I've gained back 20...this is so frustrating! Sleep doc appt this Friday, carting in my ResScan reports, my oximeter reports (mostly >92% better than daytime, thanks to my fat gut), my list of symptoms, things I've tried that haven't worked...I'm on a APAP for pete's sake with a 6-month average (just made 6 mos on the APAP) of AHI=1.3 & AI=0.1 so therapy is good...except for these wakeups . He'll wanna do the PSG that I couldn't afford last July and I still can't afford the co-pay and that sucks too

[Slinky]

Awwww, Muse. That sucks. I'm sorry you're going thru a rough spot too. Bummer. I hope your sleep doc this Friday is worthwhile!!!! I'll cross my fingers for you and watch for your report!

[Big Daddy RRT,RPSGT]

Slinky,
Having your own pulse is unusual and awesome. This will make a self titration more safe. You could consider it. You also say your not a CO2 retainer so again this lowers your risk.

Are you using the BiPAP Auto you borrowed?
What settings are you using?
What do your reports look like?

[Slinky]

I've got a PR SystemOne BPAP Auto w/Bi-Flex. It was originally set IPAP 17, EPAP 6, PS 3. Unfortunately, I had no software the first 2-3 weeks so they were wasted.

Then I'm used to ResScan so I didn't write down what pressure changes we did make assuming like ResScan EncorePro 2.2 would list the PAP settings in each statistics report. So more time wasted.

I'm currently at IPAP 17, EPAP 11, PS 5. Too soon to place any reliance on the reported AHI. I have to use Ramp 8 for 30 minutes or I can't get to sleep. I get some aerophagia above 9.5 cms but not so bad that I'm not sticking w/the settings for now at least.

CA = 0.8, OA = 6.0, H = 1.1, FL = 0.3, VS = 3.4, RE = 0.9, AHI = 7.9

Where as the first 17 days the average OA = 8.3

Yes, I have been tweaking the pressure settings on my own. I refuse at this stage of the game to go 30 days or 6 weeks or however long is convenient for the sleep doctors between pressure adjustments.

I"m feeling one heck of a whole lot worse than those 8.3 and 7.9 AHIs suggest. I'm back to needing a 1 1/2 - 2 hour nap most days. Most nights I'm sleeping about 4 - 4 1/2 hours, then awake, then maybe another 2 - 2 1/2 hours a couple of hours later.

I do sleep mostly on my back, but also do some side sleeping. On my sides, especially the right side, my respiratory rate increases. While my 02 sats don't drop I don't feel like I'm breathing as comfortably, it feels like I'm not getting quite enough air or at least not as much air as laying on my back.

I'm getting as good therapy as I was w/my VPAP Auto - but I HATE the EncorePro software. *sigh* I'd like to finally find the right pressure settings for me so I can try this PR S1 in straight BPAP mode. As much as I love my Resmed VPAP Auto I can't use it in Spontaneous mode (straight bi-level) as the pressure transitions are too abrupt for me. But if I use it in VAuto mode w/the PS set the exact distance between IPAP and EPAP so that it is running as a straight bi-level in VAuto mode the pressure transitions are smooth as silk thanks to the EasyBreathe technology.

[Komodo]

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.

Thank’s again for a great reply!

I’d like to answer a few of the issues you’ve brought up.

but your Dr ain't gonna like that you've "messed" with your machine

Quite the contrary!!!!!! My doc L-O-V-E-S the fact that I know enough about my OSA and take an active part in my therapy. It’s because of my “messing with” my Cpap, and bringing in detailed reports to him, that I was switched to a Vpap auto.

Bad lungs, OSA and no oxygen problems? This is a surprise but good

I should clear that up a little. PRIOR to therapy, there was severe oxygen desaturation, BUT, as soon as I started Cpap at 14cm, my O2 went right back into the normal range and has stayed there.

Did they use an End Tidal CO2 monitor during your titration?

No. Actually this is the first time I’ve heard of an End Tidal monitor, and I will be asking my doc about it.

That's why a Sleep Lab titration is important for people with other medical conditions like heart and lung problems

That is SO true!!!!
Not only for people with other medical problems, but for everyone. There are a lot of newbies on this Forum who read our posts about us changing our settings to improve our therapy, but they have to realize that we didn’t start this on our own, we all started off with a sleep study at a Sleep Lab.

[Big Daddy RRT,RPSGT]

Your Dr is unique if he doesn't mind you adjusting your own settings. But you still haven't found your "sleep zone"?

[Komodo]

Your Dr is unique if he doesn't mind you adjusting your own settings. But you still haven't found your "sleep zone"?

That's only because I SHOCKED him when I walked into his office with my hand written daily log, and a printed out Fully Detailed report!

I proved to him that I knew what I was talking about and knew what to do to improve my therapy. After I pointed out all my problems to him, he sent me for another sleep study, and now I'm on Vpap instead of the Cpap I started with. It's been a month on Vpap so far, and no, I still haven't found my "sleep zone". I am getting close to finding it, but I'm not there yet. I see him again tomorrow and will be going over quite a few things. After that, I'll be on my own for a YEAR before I get to see him again, unless something goes horribly wrong that is.

[Komodo]

UPDATE:

I just got back from my sleep doc.
I went there armed with a fully detailed report printout, broken down week by week, and pressure by pressure.
I went over everything with him, pointing out things as I went.
He was VERY impressed!

My main question to him was the same I started this thread with: Which therapy is better?

His answer to me was:"Go with the lower pressure."
His opinion, which may not be the same as your doctor's, is that it's better to have the lower pressure for the 95% of the night and only having the higher pressure spike up when it's needed.

Of course he said to contine monitoring my results as I have been and if there's any change, to adjust as needed.

All in all, it was a very pleasant office visit!

[Big Daddy RRT,RPSGT]

Sounds like a productive follow up!

[Big Daddy RRT,RPSGT]

Slinky wrote...
I've got a PR SystemOne BPAP Auto w/Bi-Flex. It was originally set IPAP 17, EPAP 6, PS 3. Unfortunately, I had no software the first 2-3 weeks so they were wasted.
I'm currently at IPAP 17, EPAP 11, PS 5. Too soon to place any reliance on the reported AHI. I have to use Ramp 8 for 30 minutes or I can't get to sleep. I get some aerophagia above 9.5 cms but not so bad that I'm not sticking w/the settings for now at least.
CA = 0.8, OA = 6.0, H = 1.1, FL = 0.3, VS = 3.4, RE = 0.9, AHI = 7.9
Where as the first 17 days the average OA = 8.3
I"m feeling one heck of a whole lot worse than those 8.3 and 7.9 AHIs suggest. I'm back to needing a 1 1/2 - 2 hour nap most days. Most nights I'm sleeping about 4 - 4 1/2 hours, then awake, then maybe another 2 - 2 1/2 hours a couple of hours later.
I do sleep mostly on my back, but also do some side sleeping. On my sides, especially the right side, my respiratory rate increases. While my 02 sats don't drop I don't feel like I'm breathing as comfortably, it feels like I'm not getting quite enough air or at least not as much air as laying on my back.

On these settings you have a starting pressure of 16/11 and a max of 17/12 this a very limited range. It's giving the auto very little "working" range and might be too much air while sleeping on your side. Increasing the Bi-flex or A-flex setting to 3 might help with the aerophagia.

If you are unsure where to go with your pressure, you might start over now that you have the software. Start with wide open settings, sure you'll waste some sleep time on lower settings, for a while, but you'll get a more valid 90th or 95th percentile pressure. A 90th or 95th percentile pressure is most valid with wide open settings after using it for several nights at least. You can use the reports with these wide open settings to zero in on your "sleep zone".

Start with something like a pressure support set to comfort, and a wide open range of IPAP of 20 and Epap of 5 (or as low as you can tolerate). In the sleep lab we increase the EPAP when you have obstructive apneas. We increase the Ipap for hypopneas. So if you waste a lot of sleep time on lower settings from obstructives you increase the EPAP as tolerated. If you have mostly hypopneas, you increase the pressure support as tolerated. Once you find a decent range, if you still don't sleep/feel good, you can then zero in on a more "ideal pressure" using the reports. Use the 90th or 95th percentile pressure. Go a couple of cmH2O lower for your starting pressure and use the Max pressure from your reports as the highest pressure. Or you could just use the 90th or 95th percentile pressure as a staight BiPAP pressure. You have lot's of options. Good luck.

[Slinky]

Thank you, BigDaddy.