Question about Raising Pressure

[archangle]

APAP always has apneas. I like straight CPAP.

APAP will not always have apneas unless you set your minimum pressure too low. For instance, if you do CPAP at 8, and set your APAP at 8-12 you won't have to start with apneas to get to the right pressure.

If you set it to 4-20, then yes, you'll probably have to suffer a bit until it adjusts upward.

[Pugsy]

Will do number 3 at the end. This part is just general thoughts and wondering out loud about some stuff.

You are kinda all over the place there aren't you? Some nights you max the pressure out and some night you never come close.
Some nights the pressure seems to be responding to events and other times when the events are obviously all over the place the machine sits there and twiddles it thumbs and doesn't even try to do anything. When it does absolutely nothing it makes me wonder if the normal event precursors that are needed for the machine to do its thing are even present? Is it possible that some of those "hills" are awake events being scored by mistake?

Do you know if you have a strong positional component to your OSA? Worse on your back? Or worse in REM stage sleep thing?
How come you want to stay with such a narrow range? Do you find the pressure variations disturbing?
When you had the Pro machine and used straight cpap how did those reports compare with these?

Your Clear airway index seems to vary between 1/3 to 1/2 of your AHI. July 31...more than half of your AHI is Clear airway and the bulk of them around 1 AM when the pressure does nothing. Remember this is what the machine is supposed to do when clear airways are detected. It sits there and twiddles its thumbs because it won't try to fix an open airway cessation of breathing.
Now on June 17 you had some pressure increases at approx the same time as some clear airway events were scored but you also had clear cut obstructive apneas, flow limitations and Hyponeas get flagged. Pressure got maxed out. For some reason at that time the pressure wasn't sufficient. It doesn't appear to be the norm for you unless you see this fairly often. Maybe those events were on steroids and just needed more pressure because of something oddball If I saw this fairly often I would increase the maximum just to see where it wanted to go.

We are pretty sure you don't have complex sleep apnea and those clear airway events being flagged are probably some sort of "central" that would be discounted in a sleep lab. I would think that if you were really having problematic centrals we would see them all the time every night.

Take a step back and go back to those reports where the AHI is higher and the total events are higher...remove the clear airway event totals from the overall totals and see how many are left. Remember we don't treat them with pressure anyway with these type of machines. How scarey are the numbers with CAs removed?

Have I confused you more?
Your June 19 report looks great. In your sleep log do you document how the overall night's sleep seemed to go. Frequent wakeups, restless, whatever? It appears that at least on paper you slept better on June 19 when compared to July 31 and main thing with July 31 report was what went on before the break in therapy. Looks to me like you might have been awake a good bit of the time.

If these were my reports I would first of all try to figure out if there was some positional or REM issues that might explain the times that the pressures did max out. For some reason your machine wanted to go higher but couldn't and since it doesn't want to go higher every night...this points to sometimes maybe needing higher pressures and sometime not.

If these were my reports I would try evaluate my sleep quality. Is it possible that those groupings of events which appear to be mainly central were flagged while awake or semi awake?

Finally....even if those clear airway events were the real deal we don't base pressure needs on their presence...we base pressure needs on the obstructive components (Flow limitations, snores, hyponeas and obstructive apneas) that we see on the reports. So the clear airway events have to be removed from any numbers we are looking at before we draw any conclusions about the effectiveness of our chosen pressures.

#3 – Increase in pressure
How do you know when to increase pressure? I don’t know which of those stated below I should be looking at more. Also, I know these change from night to night no matter which mask you use.
- Total Events average?
- AHI increase average?
- Pressure Average?
- 90% Pressure “average”?

You can't use Total events to evaluate pressure needs until you remove the clear airway component because we can't fix clear airway events with pressure.
Same thing with AHI...gotta remove the central component before evaluating pressure needs or responses.
Pressure average...this one I will go with as being a factor in establishing pressure needs because the machine will respond with pressure changes if it feels the need. There is a documented logical response to a need.
90% Pressure...same thing I have always said...sometimes it is spot on and sometimes it isn't. It is easily skewed by a brief 30 minute spike for some reason. It isn't the holy grail of pressure numbers for everyone but it might be for some people. If you are going to use 90% as something to look at you need to look at long term 90% number and not a night here and there.

[Starlette]

Pugsy,

I'm going to read your post tomorrow morning after I make me a mug size cup of coffee that I'll need to read and reread your post several times.
Curious, do you happen to type 70 - 80 wpm? Like I said, it took me approx. 5 hours to type mine, read and reread to make sure I said everything correctly, or at least I hope. I can't even imagine how long it took you to type a post like the one you did for me.
Lastly, if you charged us $5 a paragraph for your posts, you could retire and never have to work again

Starlette

[Starlette]

Will do number 3 at the end. This part is just general thoughts and wondering out loud about some stuff.

You are kinda all over the place there aren't you? Some nights you max the pressure out and some night you never come close.
Some nights the pressure seems to be responding to events and other times when the events are obviously all over the place the machine sits there and twiddles it thumbs and doesn't even try to do anything. When it does absolutely nothing it makes me wonder if the normal event precursors that are needed for the machine to do its thing are even present? Is it possible that some of those "hills" are awake events being scored by mistake?
You are kinda all over the place there aren't you? Yes
“if the normal event precursors that are needed” Is there a way to correct that?
“that some of those "hills”” – Could be

Do you know if you have a strong positional component to your OSA? Worse on your back? Or worse in REM stage sleep thing? I always start off sleeping on my side. Sometimes, I wake up on my back. I'll add that to my sleep journal also and track that. Regarding REM, I can hook up my Zeo and check it out for the next couple of nights.
How come you want to stay with such a narrow range? Do you find the pressure variations disturbing?
Honest Pugsy, I thought if I ever raised the pressure as you have suggest to 20cm in other posts, I’ve always been afraid that when the AHIs increase and it jumps to 20cm and that would 1) be dangerous for me; and 2) it would cause A LOT of air in my gutt which would be VERY uncomfortable. However, at your request, I'll raise maximum pressure to 20 and see where it goes.
When you had the Pro machine and used straight cpap how did those reports compare with these?
First, you have an AWESOME memory to remember that. Comparison? Looking back much better overall to my surprise. Keep in mind I wasn’t tracking Clear Airway nor the amount of events at the time just the AHI total. So the total AHI’s would have been MUCH better than I thought (We’ve gone over this before). I’ll lay it out.
CPAP from 3/20/2011 to 1/8/2012
Above 5cm (Index) and equal to or greater than 4 hours of usage = 16 nights. Removing those nights, the average between the rest was between 0 – 3. Holy smokes, I did MUCH better than I thought!!!
APAP 1/9/2012 – Present
Index = AHI – CA
Above 5cm (Index) and equal to or greater than 4 hours of usage = 3 nights. Removing those nights, the average between the rest was between 0 – 3. Holy smokes, I did MUCH better than I thought!!!
Events over over 21+ = 33 Nights. It appears that the average events were between 11-15.

Your Clear airway index seems to vary between 1/3 to 1/2 of your AHI. July 31...more than half of your AHI is Clear airway and the bulk of them around 1 AM when the pressure does nothing. Remember this is what the machine is supposed to do when clear airways are detected. It sits there and twiddles its thumbs because it won't try to fix an open airway cessation of breathing.
Ok. Understood.
Now on June 17 you had some pressure increases at approx the same time as some clear airway events were scored but you also had clear cut obstructive apneas, flow limitations and Hyponeas get flagged. Pressure got maxed out. For some reason at that time the pressure wasn't sufficient. It doesn't appear to be the norm for you unless you see this fairly often. Maybe those events were on steroids and just needed more pressure because of something oddball If I saw this fairly often I would increase the maximum just to see where it wanted to go.
OK.

We are pretty sure you don't have complex sleep apnea and those clear airway events being flagged are probably some sort of "central" that would be discounted in a sleep lab. I would think that if you were really having problematic centrals we would see them all the time every night.
Refresh my memory Pugsy, what is a central and what would that look like on SH?

Take a step back and go back to those reports where the AHI is higher and the total events are higher...remove the clear airway event totals from the overall totals and see how many are left. Remember we don't treat them with pressure anyway with these type of machines. How scarey are the numbers with CAs removed?
Index = 5.22, 6.65, 6.58

Have I confused you more? No
Your June 19 report looks great. In your sleep log do you document how the overall night's sleep seemed to go. Frequent wakeups, restless, whatever? Yes
It appears that at least on paper you slept better on June 19 when compared to July 31 and main thing with July 31 report was what went on before the break in therapy. Looks to me like you might have been awake a good bit of the time.
Agree to sleeping better on June 19. However, on the first half of 7/31, I was asleep.

If these were my reports I would first of all try to figure out if there was some positional or REM issues that might explain the times that the pressures did max out. For some reason your machine wanted to go higher but couldn't and since it doesn't want to go higher every night...this points to sometimes maybe needing higher pressures and sometime not.
Honestly Pugsy, I don’t know. I’ll also include in my sleep journal what position I was up on either side or back.

If these were my reports I would try evaluate my sleep quality. Is it possible that those groupings of events which appear to be mainly central were flagged while awake or semi awake?

Finally....even if those clear airway events were the real deal we don't base pressure needs on their presence...we base pressure needs on the obstructive components (Flow limitations, snores, hyponeas and obstructive apneas) that we see on the reports. So the clear airway events have to be removed from any numbers we are looking at before we draw any conclusions about the effectiveness of our chosen pressures.
I’ve always remembered that. Hense, Index = AHI – CA

Starlette wrote:#3 – Increase in pressure
How do you know when to increase pressure? I don’t know which of those stated below I should be looking at more. Also, I know these change from night to night no matter which mask you use.
- Total Events average?
- AHI increase average?
- Pressure Average?
- 90% Pressure “average”?


You can't use Total events to evaluate pressure needs until you remove the clear airway component because we can't fix clear airway events with pressure.
Same thing with AHI...gotta remove the central component before evaluating pressure needs or responses.
Pressure average...this one I will go with as being a factor in establishing pressure needs because the machine will respond with pressure changes if it feels the need. There is a documented logical response to a need.
90% Pressure...same thing I have always said...sometimes it is spot on and sometimes it isn't. It is easily skewed by a brief 30 minute spike for some reason. It isn't the holy grail of pressure numbers for everyone but it might be for some people. If you are going to use 90% as something to look at you need to look at long term 90% number and not a night here and there.
Understood

Pugsy, thank you VERY MUCH on being so thorough!!! However, I’ve got to take a shower and show SOME production for my day, so I don’t have the time to proofread everything several times before submitting, nor gussy it up.

Starlette

[Pugsy]

Refresh my memory Pugsy, what is a central and what would that look like on SH?

Centrals are open airway cessation of breathing....clear airway flagged events....Respironics call them clear airway and ResMed calls them centrals. Within the limitations of the machines (remember they don't know if you are asleep or not, turning over in bed or not, or just going through a sleep stage transition) they are essentially the same thing being called 2 different names.

What is meant by “twiddling its thumbs”?

Sits there and does nothing. Sometimes it is supposed to sit there and do nothing.
When it senses an open airway cessation of breathing...clear airway (central) they simply won't respond. They aren't supposed to.

“if the normal event precursors that are needed” Is there a way to correct that?

The normal event precursors are what the machine is designed in its algorithm to respond to. If they are there it should respond. If not there it won't respond. You really have no control over them short of keeping the minimum pressure up to where the pressure keeps them reduced.

The machine is designed to respond to and eliminate obstructive components or obstructive precursors that normally precede a full or partial collapse of the airway. The whole idea is prevention and not blowing through and correcting an event that has just occurred.

Take a step back and go back to those reports where the AHI is higher and the total events are higher...remove the clear airway event totals from the overall totals and see how many are left. Remember we don't treat them with pressure anyway with these type of machines. How scarey are the numbers with CAs removed?
Index = 5.22, 6.65, 6.58

You have lost me here. Not indexes...total events since you seem to worry about total events.
I can't see the events tabs for total event numbers in each category but I can backwards figure them to get close.
Take July 31. AHI 4.16 and the Clear Airway index is 2.58 and total number of events 29 for almost 7 hours.
Your AHI if we remove the CA index is only 1.58.
62% of your AHI happens to be clear airway events... so 62 % of the original total of 29 events is roughly 18 events.
Remove those 18 events from your overall total and you only have 11 events during the 7 hours. Not scarey at all.

Correct me if I am wrong but it seems like you have fixated on total AHI and total number of events and have been trying to evaluate pressure needs based on those totals. Trying to figure out a pressure to reduce a total number that has a high % or events that we don't fix with pressures.

Let's address obstructive event stuff right now. Address the centrals (clear airway) later.
Of the 3 reports below the one with the max at 13 showed one time where it wanted to go higher. Most of the time you don't need that much. I think I thought one of those with the max being maxed out often June 17 was with max of 13 but I see now it was 12.5. It is hard toggling back and forth trying to keep each one straight in my mind. Based on that re-evaluation it appears that 13 works for the bulk of the time unless you see a lot of other reports where the 13 is maxed out often.

If you are afraid that opening the max up to 20 will present problems with aerophagia and such then just try 14 or 15.
Heck, try 13.5. Don't base your decisions entirely on what I would do. Base your decisions on what you understand about what you are seeing and what you feel comfortable doing. I don't think you need much more than 13 based on these reports and even then you don't seem to need it for very long or very often and that is why I asked about possible positional issues or maybe REM sleep or heck maybe a combination of both. It wouldn't be an impossible combination. To me it really doesn't really matter so much why you need it...just that you need it and blaming supine sleeping or REM offers and explanation.
If you need it, you need it no matter what the cause. Besides it doesn't appear that there is a strong likelihood that whatever those events might need, it doesn't appear to be grossly higher than what you need for the bulk of the night. You max out often with maximum at 12.5 and occasionally at 13.0 maximum. I would think that there is a strong possibility that you only need a little more maximum to eliminate the maxing out. If for some reason having more maximum and reaching it does happen to cause a problem with aerophagia I don't see any harm in limiting the max at 13 and just compromising. It's not like we see a truck load of events present themselves when the max is reached. It wouldn't be the end of the world to hit your max every now and then for brief periods of time if reaching it caused problems.

Robysue knows that she limits her maximum and she has had to compromise. She knows that she needs a little more pressure sometimes but when she gets more pressure her aerophagia really presents much more of a problem for her than limiting the max and letting a few events slip past the defenses. Getting good sleep is much more important than a good math score.
Feeling better the next day without belly pain is more important than a good math score. Besides...and AHI of 2 isn't horrible anyway.

Now the clear airway events need addressing. I will call them centrals just because centrals contain less letters to type but I am meaning the same thing.
I am more concerned with your fragmented sleep and short hours than I am with your obstructive events and your maximum pressures. I would bet my last dollar that the bulk of your clear airway events are from restless sleep or mini arousals or semi awake events.
I don't think that they are pressure related at all. Your June 18 report was really quite excellent. AHI 2.04 with half of them being central. No big clusters or groups of anything. Notice the small grouping at both times when you first turned the machine on...at the first of the night and after the therapy break...Roughly maybe 15 minutes or so with a little grouping. I bet you were still awake or semi awake for those. Same thing for the last little group at 6 AM.
If you really had a problem with centrals we would expect to see them in bulk on this report also but we don't. It is really a great report.
So that brings us to a big question...why the big difference? This great report and the reports with a much greater event count? I don't know the answer. I think something is disturbing the overall quality of your sleep and some nights you don't sleep as well. I don't really think it is leaks unless you are having mask issues and waking up fiddling with the mask or something. There is some up and down of the leak line but it is far from horrible. I don't know if the events themselves are disruptive. We might explain it when you wake up after a large grouping of something but you didn't have it happen on June 18. So nothing is grossly consistent that might point to a reason.
Is it possible that the APAP pressure variations themselves are disruptive? Could be. That is why I asked what your reports looked like back when you had the Pro and were using straight CPAP.

I don't really like to tell someone "use this pressure". What I really like to do is get people thinking about what they are seeing and get their mind going and thinking about what is going on, why is it going on, what can I do to change it?
Will tweaking your pressures improve things? I don't know because we don't know for sure what is going on. We don't know what is behind those large clusters of events that are messing with not only the numerical data but also point to a good chance that something is very likely messing with your overall sleep quality also.
Tweaking the pressures is something that we can do to see if it helps. We feel we need to do something. Hence your original post here. It's okay to try things. Just remember that some things we can fix with pressures and some things we can't.
Don't fixate on the total numbers without understanding that part of those numbers we can't fix with pressures.

Maybe you need a tiny bit more minimum and maximum on the off chance that the events that are occurring are disrupting sleep. Maybe straight cpap would be less disruptive. Something is disruptive but I don't know what it is. About all we can do is systematically try to address things that it might be to see if we can change things for the better.

[DoriC]

Wow!! I wouldn't be surprised if Pugsy has answered the questions that half the board wants to know! These are the questions she has to wrestle with me about all the time! I wish some medical specialists out there had a copy of this one page seminar. As always,thank you for teaching Starlette and all of us. Now it just has to "penetrate"!

[Starlette]

Hi Pugsy.

I've gone over and over your responses to me. After going over all my data several times too, I came to a/some surprising conclusion(s). However, I need to respond later. Regarding your posts, you're absolutely right. It's just that I've been going over all this since 7am this morning. Again, I have to show production for my day.

What I will say is this:
Regarding the data from 2011, I wasn't as detail as I am now. The only number I show is the AHI that is orange in SH. To do all the calculations that I've done in 2012 would be major work. Definitely noticed a trend for 2012 and I'll discuss later.

At the moment Pugsy, would you mind humoring me so I can go full circle? You stated in the in the last post how to decide when to raise our pressure in apap.
QUESTION: How would you know to do that in cpap? Think this would help the others also.

Thank you.
Starlette

[Pugsy]

At the moment Pugsy, would you mind humoring me so I can go full circle? You stated in the in the last post how to decide when to raise our pressure in apap.
QUESTION: How would you know to do that in cpap? Think this would help the others also.

Not sure I understand the question? Obviously you know how to raise the pressure so are you asking how I would come to the conclusion that cpap pressure needed to be raised?

I would evaluate the same data points....only obstructive data points...the things that point to what pressure increases are designed to fix. Obstructive apneas, hyponeas, flow limitations, snores....
Totally omit the clear airways when trying to evaluate obstructive events because increases in pressure won't reduce clear airway events.

Example....AHI of say 6.2 but 3.2 of it is clear airway...that leaves 3.0 obstructive in nature. If I was sleeping great, feeling great..I wouldn't do anything. If not sleeping so great, still seeing more flow limitations or snores than I would like and not feeling so great...I might try a little more pressure to see if they would reduce in numbers...keeping one eye on the clear airways to make sure they didn't increase too.
If that AHI of 6.2 had 1.2 clear airway...then that leaves 5.0 obstructive in nature and while technically okay...I wouldn't be happy with it and I would try raising the cpap pressure to see if I could reduce that 5.0.

Another example....AHI of 4.0 and 2.2 of that is clear airway.. that leaves 1.8 obstructive..I wouldn't do anything unless again for some reason I was feeling awful, not sleeping good etc.

Only exception I might think of with an "okay" obstructive component of say 3.0 or 4.0 which doesn't sound so bad but if I saw that I was having some clusters to make up that 3.0 or 4.0 I might try to break up the clusters. I had this happen to me back when I was using the M series machine (remember no clear airways flagged at all) so my AHI was 4.4 but all in clusters and I felt crappy so I did increase my pressure a bit and I cut the AHI in half and felt better and broke up the clusters. In my case I noticed a pretty good sized difference in how I felt with AHI of 4 ish and 2 ish. Back then clear airway events and centrals were something that we never evaluated because we had no way to measure them. Now we do.

[Starlette]

Thank you Pugsy. Yes, that is the question I was asking. Thank you for your response.

Starlette

[DoriC]

Pretty good example! Mike's AHI was 6.1 last night, OA=1.4, HI=1.8, CA=2.9. I deducted the CA and it wasn't too bad at 3.2. His pressure is 10.6-13.6 and his 95%=13, been forgetting about those clusters you talk about and sure enough when I just reviewed the data again, clusters appear in those early morning hrs on all the reports so I'm going to try increasing the min a bit but leave the max as is right now. His AHI is a bit lower with cpap=12 or 12.5, (2-2.5 range) but he seems more comfortable at that lower auto pressure for a good part of the night. Of course that's just my observation, he can't answer that question himself so I'm just guessing. One more observation, I've been experimenting with both the S9 Autoset and the PR S1Auto for a few weeks on each and I've come to the conclusion that although his data is pretty similar on both, he seems to sleep better and seems more rested using the S9. And it's quieter and I just love the on-screen data and mask fit feature. Sorry for the Hijack!

[Starlette]

but he seems more comfortable at that lower auto pressure for a good part of the night. Of course that's just my observation....

Monday, 8/6/2012
You're not highjacking at all Dori, not at all. After sending you the PM information, I told you I'd update via this post at a later time. Looks like it’s now. If I forget anything, I’ll create another post under this thread. What you just stated is mostly my new discovery. 2011 CPAP Sleep Journal, I at least stated why I increased the pressure. Unfortunately with 2012 APAP Sleep Journal, I wasn't as diligent to document why I raised the pressure, meaning no documentation. You know what I discovered? The same thing you discovered with Mike. My therapy is best at a lower pressure also. That’s not to say that will work for everyone. For me and Mike it appears to work. I’ve got the numbers to prove it. I know it may appear that I’m obsessive with my numbers. However, it does give me lots of information especially what is working and what is not working and if there is trend with my therapy. SH gives me the data, I just put on my spreadsheet so I can see the changes day by day at a glace.

CONFESSION: From 7/6/2012 to present, I’ve been doing pressure summer salts going back and forth with different pressures. Why? I’ll never know. Again, I never documents why. To the point that I went to the highest pressure during this time from 10 – 13cm to 10 – 15cm up until Monday/08/06/2012.

When I recalculated the events* like Pugsy explained to me, the events fluctuated A LOT under a higher pressure. Strangely enough, you know when my BEST obstructions was (like Pugsy would say. NOTE: Now instead of using the word “Index”, I now use the word “Obstructions” on my spreadsheet)? My VERY, VERY best numbers for obstructions and recalculated events was when my pressure setting for APAP was either 8 – 11 or 8.5 – 11 (Super best setting was 8 – 11). Obstructions averaged out to .0 – 2+. This pressure setting was when I initially got my APAP at the beginning of the year. You know what the freaky thing was? Didn’t matter what kind of mask I wore, the data still looked great at those settings which was a huge surprise to me. However, the data might be slightly skewed because SH doesn’t know about the nights when I used two different masks in one night. On some nights, you’ll see where that column isn’t colored. That’s the reason why. Like I said, I don’t know what possessed me to ever raise the setting at the beginning of the year using APAP, I’ll never know. ADDED NOTE: I took a quick glance of the 90% (2012 APAP) and it appears to have been around 9 – 9.5cm while using the pressure of 8 – 11 or 8.5 to 11cm. Also, I’ve started incorporating my ZEO. So I’ll be checking my REM and deep sleep as I return to a lower setting, making sure nothing is compromised.

So, starting Tuesday 08/07/2012, I’m going back to 9.5 to 12.5cm and see if I can once again improve my data. ADDED NOTE: When I was doing some research on the Hybrid on CPAPtalk.com, I found a thread stating the Hybrid seems to do better at a lower pressure. I’d be eternally grateful if someone locates that thread, I can’t seem to find it now. Also, keeping in mind like RobySue and Pugsy and others have told us, it’s not so much about the numbers, it’s more important of how we feel. It’s a delicate balance.

In answer to your question Pugsy about pressure setting and data at 2012 APAP and 2011 CPAP, I took some data out of each year to present to you. 9cm pressure (2011 CPAP) and 9.5 – 12.5 (2012 APAP), the data appear to be the same. 8/21 & 8/23 (2011 CPAP) will slightly be elevated for different reasons. Also, where you see the X’s is when I didn’t mask up that night.

*I spent about 4 hours last night trying to replicate Pugsy's calculation into my spreadsheet, I finally did. However, I feel like a total idiot. All I had to do was go back to SH, click on the “Events” tab and calculate CA – (Hyponea + Obstructive Apnea) to the recalculated events. I will not consider it in vain though, doing the calculations for my spreadsheet brought me back to my high school days of math which I hadn’t used in years. *sigh*

Starlette

@Pugsy – Does my thinking agree with you? (Praying it does)

[Pugsy]

Yes, my thinking does agree with yours.

You saw my report from night before last didn't you? When the aliens came and experimented with me? It looks down right ugly on paper but I sure felt fine yesterday.
I think that sometimes we tend to look for answers in the numbers when there simply aren't any clear cut answers.
I wish it was that easy but it just isn't. We see maybe a few more events than we want and we think "oh, I need to change something" instead of thinking about the whole picture. Dori will tell you she is famous for that. I know where she is coming from though. She loves Mike and she has to try to "fix" things without any input from him and all she has to go on is "numbers" and maybe watching how he is sleeping sometimes. It is certainly understandable. She wants Mike to have the very best care that she can give him. I would be doing the very same thing if I was in her place. I would be looking under every rock there is to try to figure out how I could help him.
Problem is that last night he might have needed a little more or a little less pressure...might have made a little difference in how he slept. Tonight he might sleep differently and need a different change. Heck tonight he might do better with straight cpap and tomorrow night he might do better with APAP the way it was last night. We are always one step behind and don't have a very good crystal ball to see what tonight is going to be like. Even if Mike could add his input...it wouldn't solve all the problems. None of us know what is "ideal" for "all the time" because it is just nearly impossible to figure out.

What we do is try to figure out what seems to works well for us for "most" of the time and if it isn't perfect, well we have done the best we can with what is available for us to analyze. We don't have a guy sitting in the next room watching the pressures and the sleep stages to determine if a little more pressure is needed or if that central is real or not.
We don't have that guy in the next room to notice on the brain waves that a little more pressure actually seems to disrupt more sleep than it fixed an event and have him back off on the pressure a bit for this particular time frame.

We do the best we can with what we have. It isn't perfect and we can't make it perfect but it is the best that we can do and there is no reason to kick ourselves in the butt if we have done our best.

Sometimes increasing pressures in an attempt to kill some more events actually causes more sleep disruptions than it fixes.
Maybe it makes us more restless...maybe with the restlessness we end up having more "restless" centrals and even "restless" obstructive events. The machine can and will flag obstructive events while awake too. I don't see how it does it but I know they will because I have seen it myself. We just don't have that little guy in the next room analyzing the brain waves to help us out.

Pick a pressure that seems like you do well for the bulk of the time. Sounds like you have already done that. Accept that it may not be perfect for "all the time", remember when you are looking at AHI to compare only the events that pressures will fix. Those clear airway events we don't fix with pressure and unless we are having a truck load of them we just shrug our shoulders & blame them on aliens and move on. Accept that some nights it will look stellar on paper and some nights it will look like aliens experimented on you all night long. It happens...we can't possibly cover every single thing that "might" happen. If aerophagia or pressure variations with a wider range is a problem...lower the max and limit the range and accept that sometimes it is best to let a few events sneak past the defenses because they cause less of a problem than fixing them and having to deal with sleep disruptions or aerophagia.

[Starlette]

Thanks Pugsy for responding.
Did I read your alien post? I did.
*Jaw dropping* I'm actually understanding this, oh my!
In response to what you said, "We don't have a guy sitting in the next room..." Oh yes I do! However he's not in the back room, he's in my bed and alerts me when I have leak issues with my mask

Starlette

[DoriC]

but he seems more comfortable at that lower auto pressure for a good part of the night. Of course that's just my observation....

CONFESSION: From 7/6/2012 to present, I’ve been doing pressure summer salts going back and forth with different pressures. Why? I’ll never know. Again, I never documents why. To the point that I went to the highest pressure during this time from 10 – 13cm to 10 – 15cm up until Monday/08/06/2012.

Dori will tell you she is famous for that.

Starlette, Thanks for your confession, I've always wondered if I'm the only one on this merry-go-round!

Pugsy, I know you put a lot of heart into your response, probably one of your best efforts so far to help us understand. I really, really get it this time!! I'm going to pick a setting and stay with it and don't panic over "alien" variations. Can I throw 2 more questions at you? If cpap and apap give similar results and all things being equal, are there any reasons to use one or the other except for the comfort factor? Would there be the same variations? Also, a math question, when you throw Hrs Used into the mix, how does that impact the data? Mike usually sleeps about 9 hrs so with both having similar data how would that compare to someone who only sleeps 6hrs? Am I confusing you?

[SleepyToo2]

Thank you all for a very informative thread. I have actually been lowering my pressure a little at a time (only down 1 cm, so not major!) on my straight CPAP. However, I just wanted to add that I found the greatest improvement when I removed the + from the C-Flex. Then the other day I decided to remove the C-Flex altogether because I had no pressure relief during my titration study and I felt GOOD after that - my thinking was that if I set up the same conditions, maybe I would get the same effect. Too early to tell for sure, but the first few nights show an improvement. I do get a lot of clusters of "centrals" an hour or 3 before I wake up. After reading this thread, I need to determine whether they are breathing events or body movement events. Just have to figure out how to do that.

I read an animal study the other night that suggested that warm humidity may reduce UARS events, which seemed to make sense. I am testing whether that works for me or not. I should add that my obstructive events are very few - maybe only 1 or 2 per night. I also get quite a lot of variation.

Dori, my answer to your question is that I do see lower AHIs when I sleep for a long time, or when I sleep for a short time. I actually had a zero game during a 2.5 hour nap once that shows up as the best ever on SH! I believe that the time of going to sleep makes a HUGE difference - maybe it is the reduced hours, but I think for me being late to bed indicates more stress, which can definitely make a difference in the AHI.

One other thing I will have to test out - my chiropractor has a "special" adjustment to help with restless legs (my wife claims it works well!). If I have him do that a couple of times, would it reduce my "centrals" by some unknown mechanism? (I don't expect an answer - that's part of the hypothesis-generating piece to discuss with my chiropractor!)

The obsession with numbers is definitely catching. However, I believe that sleep apnea has wreaked such damage on my body that I need to try and get my life back as much as I can. The numbers are the only thing that really works for me as a scientist. I hope that one day I can contribute as much as you folks have given me through this site, so thanks again (hoping I haven't hijacked the thread!).