Request advice concerning initial APAP setting

[jonnybee]

I don't have a sleep doctor. EENT group here in town is closest thing to a sleep specialist but I figure I would be wasting my time going there. My family care physician left town, but then, she wasn't remotely knowledgeable concerning sleep matters. My DME nurse is of little help; she just issues the equipment. So, since leaving the sleep study, I have been on my own and for that reason I am calling on the knowledgeable members here to give me your suggestions.

Left sleep study five months ago with CPAP prescription with setting of 5cm. I ended up with a ResMed Elite which, as most know, is strictly CPAP. For the last three months AHI has been somewhat erratic (a lot of clusters) with an average (over three months) of 2.3. Highest AHI during the period was 12.2; lowest 1.2. with remainder varying between 1.5 and 6.0. Initially, I realized a significant improvement in quality of sleep, general feeling, and lack of sleepiness during the day but over the last three months that improvement seems to have disappeared. After reading many posts here, I decided that maybe I should try and exchange the CPAP for an APAP since the constant pressure doesn't seem to be doing the job for me.

Anyway, I saw the DME today and was able to arrange a swap for an S9 Autoset. The swap is costing me $300 out of pocket but that's to be expected I figure.

The DME said the Autoset should be here tomorrow. So, my question is, "what initial pressure settings (min and max) should I try"? Just from what I have read here, I'm thinking initial settings of 4 and 9 might be good for starters. What do the experts think?

Thanks in advance.

John

[LarryD]

My DME set my auto from 4 to 20cmH2O. I'm leaving it there for the time being. I am seeing variances from 4 to 8.1. with the average being between 4 and 5.5 most of the time.

[SleepingUgly]

My DME set my auto from 4 to 20cmH2O.

Even my sleep doc, who I thought was at least somewhat knowledgeable, thought 4 to 20 was OK. You'll find most people here disagree with such a wide open setting. One problem I experienced with wide open settings is that the huge swings in pressure would wake me.

I am no "expert" so take my advice with a grain of salt. Are you planning on keeping EPR off? EPR complicates things a bit, so if you can exhale comfortable without it, I'd leave it off just so you have one less variable to consider in your various permutations. If you were titrated to 5cm, that's so low that there's no real harm in having your minimum be 4, if that's what you like. I'd probably go with 5, but that's just me and based on one person's report that they were told that at Stanford they don't use less 7cm (or some such thing). I don't see 9 as unreasonable for a maximum, either. You can always tighten the range up a bit after you see where you settle. OR you could start out with 5-7, and later shift it up.

You'll want to get the Rescan software. The first thing you'll want to monitor are your leaks, and make sure you set the S9 to the kind of mask you're using--full face, nasal, or pillows. You're going to need to carefully document your settings and how you felt the next day. Once you start messing with settings on an APAP, with your AHI AND how you feel as the outcome variables, it can become a bit of a mess with so many possible combinations available (e.g., 5-9 with EPR=1 vs. EPR=2 vs. EPR=3 OR 6-10 with EPR...). Keep your settings the same for at least several days to a week, unless there's a compelling reason not to. There's so much variability night to night that any one night isn't very telling.

[Lizistired]

If I had been on straight 5cm, I would set auto at 5-9. Check the next day and see where the machine wants to be. If it reports apneas whenever it gets below 6 or 7, I'd raise the minimum to that. If it keeps banging the maximum and has apneas there I would raise that, but probably not more than 1cm at a time.

[jonnybee]

I have the software and monitor it diligently. The machine is set to EPR 3 but, as I remember, 4cm is min so I probably wouldn't notice a lot of difference. Maybe I will turn EPR off during the "trial and error" process.

Thanks for the inputs.

John

[jdm2857]

You want to wind up with a minimum setting just below the pressure that the machine is at for most of the night. The maximum is less important, as long as it is not preventing the pressure from rising to a level that is effective at minimizing your events. The maximum setting was more important on older APAPs which had a tendency to "run away" with pressure increases under certain circumstances. The newer APAP algorithms have greatly reduced the chances of that happening.

[Lizistired]

You can set the EPR for ramp only if it makes it more comfortable to get to sleep.

Hey, don't froget to update the equipment in your signature!

[robysue]

I have the software and monitor it diligently. The machine is set to EPR 3 but, as I remember, 4cm is min so I probably wouldn't notice a lot of difference. Maybe I will turn EPR off during the "trial and error" process.

Thanks for the inputs.

John

On the S9, EPR *never* lowers the exhale pressure below 4cm if I recall the documentation correctly. So at 4cm, EPR won't kick in regardless of its setting. On the Autoset, when the pressure goes up to 5cm, EPR will lower the exhale pressure temporarily to 4 cm (4 = 5 - 1) regardless of the EPR setting. When the pressure goes up to 6cm, an EPR setting of 1 lowers the exhale pressure to 5 cm (5 = 6-1), but EPR = 2 and 3 both lower the exhale pressure to 4 cm (4 = 6-2). Once the pressure gets up to 7cm, the EPR setting is just subtracted off the current pressure level for the temporary reduction in pressure:

At 7cm, EPR = 1 means exhale pressure is temporarily reduced to 6cm
At 7cm, EPR = 2 means exhale pressure is temporarily reduced to 5cm
At 7cm, EPR = 3 means exhale pressure is temporarily reduced to 4cm

At 8cm, EPR = 1 means exhale pressure is temporarily reduced to 7cm
At 8cm, EPR = 2 means exhale pressure is temporarily reduced to 6cm
At 8cm, EPR = 3 means exhale pressure is temporarily reduced to 5cm

And so on ...

[jdm2857]

One more thing. With an APAP, it's important to test mask fit at the maximum pressure setting, not the minimum pressure. You don't want leaks to start when the machine increases pressure during the night.

[pap4life]

Since you will now have an APAP with the intent of better pressure configuration, I would leave it at 4 -20cm and let the machine be your counselor, after all thats the intent of the CPAP manufacturer. Give it a few weeks and then check the results.

[ozij]

Since you will now have an APAP with the intent of better pressure configuration, I would leave it at 4 -20cm and let the machine be your counselor, after all thats the intent of the CPAP manufacturer. Give it a few weeks and then check the results.

For some people, the machine's counsel may be in error: it will zoom far too high. Since you were doing reasonably well at 5, and stick to 5-9 for starters. If you find the pressure constantly at the max (9) you can start raising the max, but given that you have an Rx, I see no reason to start out wide open.

O.

[dtsm]

For some people, the machine's counsel may be in error: it will zoom far too high. Since you were doing reasonably well at 5, and stick to 5-9 for starters. If you find the pressure constantly at the max (9) you can start raising the max, but given that you have an Rx, I see no reason to start out wide open.
O.

I also think this is a good place to start. Also keep in mind Robysue's post re EPR and adjustments to be made if you use EPR. Get the software, monitor your results for the first week and then you can make tweaks.

[jonnybee]

Many thanks to everyone for your inputs. After I get the autoset and try it for a few days, I will report back.

John

[jonnybee]

Used the S9 Autoset last night for the first time. Had a good night's sleep of 7.0 hours. Used settings of 4.0/9.0.

This morning, machine showed AHI of 3.1. Charts showed pressure banging on 9.0 often which surprised me since my sleep study titration/prescription was for cpap 5cm. Also showed more centrals than previously.

I plan to increase the settings tonight to 5/12 and see what happens. Anyone have suggestions? Is this a reasonable approach?

John

[Tired Linda]

I plan to increase the settings tonight to 5/12 and see what happens. Anyone have suggestions? Is this a reasonable approach?

John, if this were me, I'd leave the settings alone for a few nights, mabye a week. An AHI of 3.1 for the first night is pretty good. Give yourself a chance to get used to the whole thing, and see if things settle down on their own. Make sure the leaks are under control. You can always raise the pressure later.

Linda