Do I need higher pressure if my AHI is still high?

[snoozebabe]

This was mentioned briefly by another poster, but it's worth reiterating-- an AHI above 10 is too high. Something is not working for your setup, and you should definitely consult with your doctor about that.

One piece of information I haven't seen from you is what kind of residual events you are having-- are they obstructive in nature, or does your machine record them as (possible) central apnea events? Because it makes a big difference in how they would be treated. If obstructive apneas or hypopneas, then it is likely that your pressure settings are not quite right. But if your events seem to be central (neurological) in nature, then increasing your pressure settings is not likely to be effective and in fact may make things worse. Some people have central apnea events "naturally", and some, like me, get central events when put onto a CPAP or bilevel machine. In either of those circumstances, a doctor may prescribe a different type of machine-- ASV (adaptive servo-ventilation). These machines are more sophisticated (and more expensive) than CPAP, APAP, and bilevel machines. The ASV has been extremely effective for both me and for my dad.

Yes - I am missing that one piece of information too, coz I don't have any software at the moment to monitor that. I understand this piece of information is critical - it will show whether my events are obstructive or central. I will purchase the software to check on this.

However, my sleep study did not show any central apnea events though my AHI was 58. The oxygen levels in my brain were not dangerously low and still within the acceptable range. So I don't suppose I might slip into any central apnea events with the CPAP. But I know. I should verify this with the software proper.

Two nights ago I adjusted my pressure range to 9 - 15. It's a huge jump from 6 - 14, but I just wanted to give it a try to see if it works in lowering my AHI. It was more difficult going to sleep at that pressure so I was glad that my machine has a delay button that allows the pressure to stay normal for a while. The following is my results so far.



As you can see, my AHI has fallen slightly. I must report though that it feels like the first nights of my therapy all over again. I woke up several times the first night with the higher pressures and didn't feel refreshed even after a full 8-hour sleep on the 2nd night. I actually felt better before the adjusted pressure even though my AHI was slightly higher then. Well, I think perhaps all this is only the result of not being accustomed to the higher pressures and I'm thinking my body will adjust as I go along. So, I will allow my machine to stay at this pressure for a while, until I get comfortable with it.

Meanwhile, I should purchase the software to track my progress more accurately, to see if there are any anomalies in my events.

Thanks to everyone here who has offered me advice, help, comfort and warnings. All your comments and input have been valuable and helpful in giving me a full picture of the situation, including the risks involved, so at least I'm going about this with eyes wide open.

[ozij]

Hi snoozebabe,
This is a longish post, but please read all of it anyway...

Central Apneas on APAP machines
The NRI in your chart refers to Non Responsive (Apnea) Index.
Non Responsive Events in DeVevilbiss English are those events the machine is programed not to respond to.
Not exactly exactly a correct use of the King's (or Queen's, or the Republic's) English, but what have you.

All APAP machines do their best not to respond to central apnea events -- events that do not need a pressure raise.

DeVilbiss's way of distinguishing a central apnea from an obstructive one is by defining as Non-Responsive any event in which the flow drops lower than 95%. It's a statistical definition which works for about 85% of the time -- according to DeVilbiss.

You NRI is your index of events to which your machine will not respond. They may be central events, the may also be obstructive.

Information in your charts
The pressure plateau time of 3% means that your pressure what stuck at the highest level for only 3% of the night during the reported period. That, to my mind would have been an indication that there is no need to change the maximum pressure.

I also would not have changed so dramatically from 6 to 9 at the minimum -- I would have followed the advice given by many of the above poster to raise the minimum 1 cm. at a time -- or less of that were possible on your machine. But you've done that already -

We're only looking at one night's data for the new pressure -- but on that single night we can see a number of interesting things:
There's a large drop in the number of apneas the machine will not respond to, a very small drop in the events the machine will respond to (compare AHI - NRI), And concurrently, there's a climb towards the maximum pressure.

I would not propose any change base on this data, but if this trend continues, I think it can be explained as follows:
When the minimum pressure was 6 you were having apneas with extremely low flow, and the machine was not responding to them.
As you raised the minimum pressure, there were less of those events to which the machine did not respond - a hint that in your case, they may have been obstructive.

Understanding APAP therapy, in general, and DeVilbiss's in particular
The following thread about APAP algorithms and the ensuing discussion of the Devilbiss APAP algorithm and the links in that discussion may help you understand more about your therapy .

DeVilbiss have excellent webinars (web seminars) about autotitration here: http://www.devilbissclinicaleducation.com/ondemand. I found the time I spent studying them very rewarding.

Welcome to the forum, and good luck!

[Mike6977]

too high of a pressure can actually cause Central Apneas (not good)

And I wouldn't rely on ResMed's FOT to correctly ID centrals...Not without a controlled study conducted by someone unrelated to ResMed.

Dr. D. Rapaport of NY Sch of Med countered: OSAs warrant treatment at AHI of about 20. SDB can probably be ruled out at an AHI of 10.

AHI is a rather coarse and unthinking score, imho...Say I have an AHI of 9, and those 9 events average 30 seconds to more than a minute...I could also have a cluster-cloud of sub-clinical (<10 seconds) OBs, CTs and Hypos...Would Dr. Rappaport rule out SDB and deny me an xPAP?

------Dr. Rappaport------


He looks sleepy to me.

My own doctor who holds MDs in Internal medicine and Pulmonology medicine would NOT take upon himself to OK my request for boosting my pressure by one to two centimeters without a new PSG.

But would he approve a raise of .2 centimeters, watched closely for two weeks in your software?..Then, perhaps another raise, same amount and time?..Imho, such tiny, incremental raises do not demand a PSG — or if they do, then they also demand a rather large wallet.

I'd rather do it this "home-schooled" way than jump the pressure 1 or 2 centimeters, and then rely on a single night's PSG "snapshot" as definitive data for the next 6 months.

JUST SHOW ME, black (or color) on white, data from your CPAP, proving your own results on it that you have reduced your AHI for a week!!!

My ResScan, after 06.10.11 till today, small size:



My ResScan, after 06.10.11 till today, large size:

http://users.rcn.com/mcherni/Jume%2010, ... 0large.gif


Sleep diary of my ResScan: 05.01.11-to-06.10.11...I was on CPAP then, 10.4, and my AHI score was a lot higher than the post 06.10.11 charts...I switched to auto-pap, did my own dialing, base of 10.4, gradually raised my top to 15.6, not as gradual as .2cm per two weeks, but that advice is from 20/20 hindsight.

http://users.rcn.com/mcherni/05.01.11-t ... -RULER.rtf


Zipped or self-extracting WinRared detailed-data available via email, just PM me a request.

“There is not much association between the AHI and anything else—sleepiness, muscle dysfunction,” or other markers for SDB, claimed Dr. Sullivan,

On this we agree...As my AHI has steadily decreased, now ranging AHI <1, I am more dazed and tired than before I started xPAP.

And I miss my wonderful, pre-xPAP "David Lynch does IMAX 3D" dreams, even the 10% that are nightmares...Always the same damn nightmare, too: me running for my life in the desert on a starry night, falling to my knees, and seeing an ELE impact 300 miles away, then the blinding white flames rush over me like a 600 mph tide, and I wake up instantly, heart pounding.

My shrink says I should cut down on the spicy food.

Best wishes to all, NeoCons included,

Mike

..

[BrianinTN]

Since I been on this board I have never seen from any of the posters, including you, RG, Pugsy, BlackSpinner, Brenda, and others, who are often rendering medical advice about pressure changes, showing exactly what they did and how they carried out their own process of AHI reduction by changing the CPAP pressure. I am not talking about others doing it, PSGs, books, articles, stories, etc.

Now I'm mad. You are the KING of dishing out medical diagnoses with incomplete information. You'll cite one sentence in some academic journal where it says that that X condition can cause symptom Y, and if a patient pastes data showing symptom Y, you immediately jump to the conclusion that they must have X. I remember one of my very first threads around here. You tried to insist that I must have an underlying neurological condition because it would be "impossible" to have CompSAS without that -- all because you didn't understand the very basic point that an ASV is a legitimate prescription for multiple types of breathing problems. You have "diagnosed" all kinds of people here as not having OSA because their AHI is low -- despite the data those people are linking coming while treated.

Pugsy and RG are two of the kindest and most helpful people here. They also understand basic data analysis. They articulate their points clearly and patiently. And while neither has had no reason to go through a recent experimental design themselves, they have carefully watched, observed, and commented as other posters like myself have painstakingly provided their data. You want to know what the irony is here (and why I'm red hot right now)? Because in my ASV thread, you made this jack-#$& comment:

I can't believe it that this thread showing 4 Hypopneas out of 5 AHI still continues.

So someone presents you with detailed data using the scientific method, and you blow it off. It's impossible to please you, Avi. You communicate poorly, often fail to understand the medical journals you link, and frequently make statements that are not at all relevant to the discussion at hand. And when someone calls you out, you cry foul and insist they're being mean to you.

Avi -- when you have a disagreement with one or two people, that's just life. When it seems like the whole world (or in this case, the whole board) is out to get you, MAYBE THE PROBLEM IS YOU.

If you want to continue thinking that you and your doctor are so smart, that's great. But don't you dare drag Pugsy and RG, who both contribute invaluably to this board, through the mud in your ignorant crusade.

I knew I should have gone to the pool today rather than catching up on readings posts.

[DoriC]

I knew I should have gone to the pool today rather than catching up on readings posts.

Sending you a hug (((Brian)))! Maybe it's not too late to grab a swim or at least take a cold shower!

[Mary Z]

snoozebabe, I didn't realize until I looked at your chart that you're not using your CPAP 100% of the time each and every night. You might be right in changing your pressure, but why don't you perfect your compliance. Use the machine all night, every night, and naps.

[ozij]

Well said Brian.

And I join Dori in hoping you still have time to go to the pool.

[moresleep]

I am also one who would agree a low AHI, while nice and a large step in the right direction, is not the be-all-and-end-all of successful treatment. My AHI is usually well below <5, yet the way I feel the next day varies considerably. Got rid of the mouth breathing (tape), got rid of the mask leaks, keep sinus infections at bay so that I can actually breath through nose, try to sleep on side, have the head of the bed elevated so fewer problems with GERD--I've done all of that, and all of it has helped; but there are still some unknown factors that sometimes screw up my sleep. A machine recording waveform data would be nice, and maybe I'll get one of those sometime. One's own personal sleep doctor in residence would also be helpful in figuring things out; but, then again, look what happend to Michael Jackson, who did have one of those...

[snoozebabe]

snoozebabe, I didn't realize until I looked at your chart that you're not using your CPAP 100% of the time each and every night. You might be right in changing your pressure, but why don't you perfect your compliance. Use the machine all night, every night, and naps.

Oh, but I do. Ever since I got the CPAP, I have never slept any sleep without it. My condition has improved so much that I would not want to go to sleep without my CPAP because I really dread the uncontrollable daytime sleepiness returning. In fact, now I wonder if I would be able to fall asleep without the machine. I use my CPAP like how I would use breathing apparatus if I dive underwater.

Strange you should say that though. Maybe some nights I wear the mask, but it leaks so much that it doesn't register as being used? I do find that if I sleep on my side, it puts pressure on the silicone and the air might leak. But my machine never registers any leak.

[rested gal]

I am also one who would agree a low AHI, while nice and a large step in the right direction, is not the be-all-and-end-all of successful treatment. My AHI is usually well below <5, yet the way I feel the next day varies considerably.

Well said, moresleep!

I've long thought there can be sooooo many OTHER health reasons why a person can feel tired, sleepy, or just plain awful even if CPAP is doing its part of the job (keeping the airway open) fine. There can be other health issues, completely separate from "OSA" that might need to be addressed before a person can feel "better" -- no matter how low the therapy AHI. Effective CPAP therapy is not a magic bullet to cure all ills.

Could my "Pressure Needs" have changed?
topic started by jabman - Aug 9, 2011
viewtopic.php?p=623655#p623655

How do you know if you feel as good as you can?
topic started by SnoozyQ - Jan 18, 2011
viewtopic.php?p=557841#p557841

APAP seems to work, but still tired
topic started by turbosnore - Dec 12, 2008
viewtopic.php?p=321611#p321611

Two weeks, CPAP is working great.. but I feel worse!
topic started by KenC - Oct 27, 2007
viewtopic.php?p=220278#p220278

[DaveLP]

For me, higher pressures correlate to many more hypopneas and a small number of central events. My prescribed pressure produces some of the lowest AHI numbers. Some of the reason for this is that with a nasal mask, I get EPI rises with more pressure due to mouth leaks. Achieving the correct balance can be time consuming. I find that a small range of 1 or 2 cm h20 above my prescribed pressure results in better therapy for me.

[sickwithapnea17]

So is 18/14 auto bipap a better setting for me than 10/4 bi level because it won't cause central apneas? I was still getting some ca's on my bipap titration report. my 7 day AHI seems lower on 18/14 but I feel tired still when I wake up- it seems like my lungs are working at that high of a pressure

[Pugsy]

So is 18/14 auto bipap a better setting for me than 10/4 bi level because it won't cause central apneas? I was still getting some ca's on my bipap titration report. my 7 day AHI seems lower on 18/14 but I feel tired still when I wake up- it seems like my lungs are working at that high of a pressure

A reduction in pressure from 18/14 to 10/4 is a HUGE reduction and likely not anywhere near therapeutic pressure.
It will likely cause a significant increase in your AHI. I cannot advise such a huge change.
For anyone to give you anything more than general ideas we need a starting point.. Software reports. Were you able to get the software installed? Did you need a card reader adapter for the SD card? Does your computer have SD slot?

Tired when you wake up could be any number of things. You give us nothing to base an opinion on. Hours of sleep. How long using the machine? Other health conditions? What is that AHI average?

It would be better if you started your own thread with your own problems and provide much more information. That way everyone could see it and your problem won't get lost in someone else's thread.

[snoozebabe]

My pressure range is now 14.5 to 18.5. My AHI has dropped but is still averaging 7 to 8 and sometimes it still goes beyond 10.

I hesitate to adjust my pressures any higher. I can't track if I'm having Central Apnea. The software report is only showing hypopnea events. Those are quite frequent.

I do not have a doctor to consult locally as medical care in my area is not so advanced. Perhaps I might need to seek medical advice in another country and until then I would have to live with the numbers.