First night with Intellipap Auto

[DaveLP]

Last night, I received my Devilbiss Intellipap Autoadjust with Smartflex and humidifier. I researched this machine for a long time before deciding that is was the best one for me, IMO. For the last two years, I have been using the Respironics Remstar M100, a fixed pressure CPAP plain Jane model.

My sleep study, two years ago, set my pressure at 9.0. I have always thought that I wasn't getting the benefit I expected from CPAP. My daytime sleepiness subsided after CPAP, but only on rare occasions did I wake up raring to go. I was still experiencing slow memory recall and tiredness. So, I decided to look around on my own for an auto machine that was full featured and reasonably priced. I found that in the Intellipap auto.

So, first night ... I unpacked it. read the directions, and set it up. I noticed that it was set to 4 and 20, the full range. Being prescribed 9cm pressure, I didn't want to take a chance on having it send me to 20 the first night. I looked up the codes and set the range from 6 to 12, creating a wide range for it to settle into.

I slept well and awoke feeling a little spark of restfulness! To my surprise, when I read the smartcodes and entered them into the website, my report tells me that I maxed out at 12cm with an AHI of 13.5. I will post the Intellipap report below for discussion. I welcome comments and observations. I have set the max pressure to 13, to allow it a little more wiggle room for tonight.

[Bluecat]

I would rather suggest you set the minimum pressure just under your titrated pressure and leave the maximum wide open to start with.
That would be 8-20, and tighten the range slowly depending on the results.

[DaveLP]

I would rather suggest you set the minimum pressure just under your titrated pressure and leave the maximum wide open to start with.
That would be 8-20, and tighten the range slowly depending on the results.

That's probably good advice. I will do that. I'm having trouble on this board inserting an image in my post. I have a pdf file that I'm going to have to create a jpeg from and will post my report as soon as I can. Below is the summary data. The pressure plateau time is 16%, which indicates the percentage of time spent at the highest pressure setting. This does indicate to me that I am close to the correct pressure. I do agree, though, that I would be better off to let it max and see what happens.

Pressure Plateau Time
Represents the percentage of time the AutoAdjust spent at the upper pressure setting. A value of 10% or more indicates a possible need to raise the upper pressure setting to allow higher pressures.

Last 90 Days Last 30 Days Last 7 Days Last Day
% Days at least 4 hours 100%
Day Count 1
Days at least 4 hours 1
95th Percentile Pressure 12.0
90th Percentile Pressure 12.0
AHI 13.5
Pressure Plateau Time 16%
High Leak Flow Time 0%
NRI 0.25
EPI 5
SmartCode FPZG-FNF-9QY0

[Pugsy]

I would also think about raising the minimum. These machines take time to raise the pressure in response to event triggers. If it takes too long the events come and go before the machine can get to where it needs to be to adequately prevent the events. This happened to me. In my case 8 cm minimum helped some but still had AHI near 10. I started increasing the minimum till I got to 10 cm where my AHI was reduced to less than 4 consistently. I do leave the max wide open because I do have the software and I do have times where the machine wants to give me up to 18 cm. It is my choice and suits my needs. It may not suit others. Maximum doesn't really come into the picture unless the machine thinks it needs too.

Since your original RX was for straight cpap at 9 cm, I would suggest closer to 9 (or even 10) cm minimum. At 6 cm it can't respond quick enough. Especially since it is reporting that you are staying near the max a good bit of the time.
The minimum setting is what is most critical. Tight range is okay to use but the minimum has to be closer to needed pressure.

I see one comment similar to mine already.

[DaveLP]

I would also think about raising the minimum. These machines take time to raise the pressure in response to event triggers. If it takes too long the events come and go before the machine can get to where it needs to be to adequately prevent the events. This happened to me. In my case 8 cm minimum helped some but still had AHI near 10. I started increasing the minimum till I got to 10 cm where my AHI was reduced to less than 4 consistently. I do leave the max wide open because I do have the software and I do have times where the machine wants to give me up to 18 cm. It is my choice and suits my needs. It may not suit others. Maximum doesn't really come into the picture unless the machine thinks it needs too.

Since your original RX was for straight cpap at 9 cm, I would suggest closer to 9 (or even 10) cm minimum. At 6 cm it can't respond quick enough. Especially since it is reporting that you are staying near the max a good bit of the time.
The minimum setting is what is most critical. Tight range is okay to use but the minimum has to be closer to needed pressure.

I see one comment similar to mine already.

Good idea. I'm a two year veteran of CPAP, but with a manual machine. Setting up and using an auto machine is a little new to me. I hadn't thought about the fact that some of the AHI could have been during escalation and ramping up of the pressure. That makes good sense. I have noticed that the 16% spent at the max of 12 indicated that I was close to my sweet spot. If that were 80% I would think I was way under the correct max. I will set the min to 9 and leave the max at 20. My first thought was, "How can my sleep study show 9cm and my auto is taking me to 12cm?". I'm beginning to understand now that range is more than allowing auto titration and I need to find the range that controls my apnea from the start, with enough headroom to allow for incidents such as head position, back sleeping, and other things that might require a transient higher pressure.

I'm still wondering why my machine came set up for 4 and 20, the full range, when my prescription states 9cm. I'm thinking that my reports would be skewed by the slow ramp from 4 and really wouldn't tell me much with the wide range of pressures allowed.

Thanks for your comments!

[Slartybartfast]

4-20 is the full range of the machine. It didn't come set up that way, rather, that is the full limit of the machine's pressure range. So perhaps it's better to think of it as having come not set up at all. You need to dial in the minimum and maximum pressure limits. Pugsy's right. If your titration recommendation was for 9 cm, then you need to set the minimum just below that. The usual advice on this forum is for 2 cm below the titrated pressure. So that would be 7 cm. But since you're coming from CPAP to an Auto-PAP, you might also want to set the Pminimum to 9 for a night or two and then decrease it to 8 the next night or two, then 7 for a few nights and see what the trend is in your numbers. The top limit isn't really as important. Unless the machine runs away with you (unlikely) there's really no need to set a maximum pressure.

The Intellipap is sensitive to snoring as a trigger to increase pressure, just so you know. You might also want to play around with the i-rounding and e-rounding controls to soften the onset and cessation of airflow at the beginning of inspiration and end of expiration. When I first used my machine, it felt a little like Darth Vader's ventilator until I played with those settings.

And expect your reported AHI to be somewhat higher than the numbers you'll see reported by other users. I have both the S9 Autoset and the Intellipap, and the iPAP always reports AHI at around twice that of the S9. I think that's indicative of differences in the way the two machines score events.

You've got a good machine. I expect you'll like it.

[Emilia]

Dave, I sent you a PM last night... go to your messages...click the message link in the parentheses at the top left next to User Control Panel.

Since your 90/95th%tile was a 12, I'd also suggest bringing up the minimum to 10 and move the top number to 14 and see if that brings the AHI down.

[DaveLP]

I set my intellipap to 9min and 16 max to see what pressure it settled on. I spent the first hour in bed unable to sleep with the pressure rising until it was intolerable. My feeling was that I got no sleep in the first hour, although I suspect that I started to fall asleep several times and the pressure went up to the max. I do know that there were a couple of times that the pressure rose to 15.1 on inhale while I was periodically feeling the rise and leaning over to see where it was set. Around 2am, I set the max pressure back to 13 and finally fell asleep and slept through the night. All night long I was awakened frequently with air blowing through my lips, in spite of the fact that my chin strap was firmly pressing against my lower lip. EPI was 7 per hour last night. I guess the 95th % pressure reflects the 13cm setting I changed to after over an hour of non-sleep.

Tonight I plan on sleeping at 9.5cm (my DME setting for the old CPAP) to get a base reading for what happens at the singular pressure. This machine seems to want me at max. As I said, at 16, it had me up to 15.1 before I could get to sleep. At that level, I was restless and blowing air through my lips frequently. I have a beard, so taping isn't an option.

I ordered the card reader with the cable and the software yesterday, so I should be able to look at periodic info graphically soon.

Last night's numbers
% Days at least 4 hours 100%
Day Count 1
Days at least 4 hours 1
95th Percentile Pressure 13.0
90th Percentile Pressure 13.0
AHI 16.5
Pressure Plateau Time 4%
High Leak Flow Time 0%
NRI 1.00
EPI 7
SmartCode FX6B-FGD-CGYE
While Breathing Hours Last Day 6.0

Previous night's numbers
% Days at least 4 hours 100%
Day Count 1
Days at least 4 hours 1
95th Percentile Pressure 12.0
90th Percentile Pressure 12.0
AHI 13.5
Pressure Plateau Time 16%
High Leak Flow Time 0%
NRI 0.25
EPI 5
SmartCode FPZG-FNF-9QY0
While Breathing Hours Last Day 6.9

[ozij]

My experience in Auto mode on a different machine was that too low a minimum resulted in higher maximum pressure needs.
So, after get a your base rate at fixed 9.5, I suggest you return your max to the tolerable 12, and see how a minimum of 9 affects it.

Some people have to put a cap to the maximum pressure on any machine they use. This may be your case too.

[Guest]

My experience in Auto mode on a different machine was that too low a minimum resulted in higher maximum pressure needs.
So, after get a your base rate at fixed 9.5, I suggest you return your max to the tolerable 12, and see how a minimum of 9 affects it.

Some people have to put a cap to the maximum pressure on any machine they use. This may be your case too.

For tonight, I'm capping the min and max at 9.5, my prescribed pressure. That will give me an idea of what was happening on CPAP, in terms of AHI and EPI. Then I will up the max a point at a time to see how my numbers look. I already know that it is elevating my pressure and causing more AHI at the higher pressure along with a terrible number of exhale puff issues. My wife hears me blowing air through my lips and reaches over to wake me up when that happens.

[Emilia]

I'd say that most of the problem is that you are losing therapy out your mouth. If you cannot tape, and the chin strap is ineffective, you will need to consider either a hybrid or FF mask to remedy this.

As for pressure..... my case was not difficult, but I was able to lower my AHI significantly at the beginning by slowly moving my minimum pressure up half a notch and then another half a notch. That one full notch was all I required to lower the AHI, but you may need more half notches to succeed. I did keep my upper pressure at 2 notches above my titrated pressure of 8. It is process that will take some time... for some they find that sweet spot easily; for others, it may take more experimentation. Once you have some data to work with, it will get better and you will find your spot. But....you won't benefit until you get the mouth leaks under control!

You can try to train yourself to keep your tongue on the roof of your mouth just behind the ridge behind the upper teeth. If you can practice that and master it, you will keep your mouth closed and your tongue from falling back.

The only other option I see is to shave Good luck!!

[DaveLP]

Thanks, Emelia. I agree that I am losing therapy through my mouth. This happened with my fixed pressure CPAP as well. I keep my beard trimmed to about 1/8" and I have a couple of FFMs that work well that way. One is a Fisher-Pakel with a double layer seal.

I'm a side sleeper who ends up on his back every morning. When I sleep on my side, the mask tends to contact the pillow and leak. I have wide shoulders and the contour pillows aren't deep enough for side sleeping with my spine straight. My head tends to dip.

Anyone know of a thick temperapedic pillow that is available. It needs to be at least 2 inches thicker than the standard contour pillow.

[Emilia]

You might check your Yellow Pages for any foam dealers in your area. If not, good fabric stores usually carry varying depths of foam in different firmnesses. If you have a good foam/fabric place that carries extra deep foam, take your contour pillow with you and have them make a template and cut the foam to match. Then you just need to get a large pillow case or make one.

[DaveLP]

Below is my baseline data for my prescribed pressure at 9cm. I think this confirms that my issue is definitely EPI ... I'm losing therapy through my lips, as several have commented. I had 31 exhale pressure index events, but my AHI was 11.5, the lowest of my first 3 days with the Intellipap auto. I think it's time to trim the beard close and use the Fisher-Paykel FFM and see how it affects AHI.

Days at least 4 hours 100%
Day Count 1
Days at least 4 hours 1
95th Percentile Pressure 9.0
90th Percentile Pressure 9.0
AHI 11.5
Pressure Plateau Time 0%
High Leak Flow Time 0%
NRI 0.25
EPI 31
SmartCode FRAF-FHF-VVYB

While Breathing Hours Last Day 7.5