question about pressure AGAIN

[DoriC]

Those centrals look something like those my husband gets when he's restless and/or leaking and holding his breath when he's turning over. I've been able to observe him holding his breath first hand and make note of the time and sure enough the times coincide on his reports.

[oak]

interesting Dori. he is so lucky to have you.

[oak]

flow limitation chart from same night (last nite) per Pugsy's request:

[DoriC]

I'll be interested in what Pugsy has to say. Those FL look familiar too!

[Pugsy]

Can we also see a FL graph from a 9 cm cpap pressure night? And the AHI event category breakdown for that night also?

Looks like the machine is wanting to increase the pressure in an effort to reduce the flow limitations. It sure isn't because of hyponeas or obstructive apneas. Remember snores and flow limitations are the main targets that apap machines try to prevent from ever happening because they are indications of a reduction in air flow most commonly caused by a collapse of the airway but not making criteria for a full grown OA or hyponea. It tries to prevent them from ever growing up.

[oak]

here is one from August 1 with pressure set at constant 9 cm:



thanks so much for your help!

[oak]

oops here is the AHI chart from the same nite-August 1

[Pugsy]

Do you have a copy of your diagnostic sleep study and/or titration study or at least the condensed version?
What was your diagnostic AHI and the breakdown in categories if they mention it?

How is your sleep (once you get to sleep..I realize that there is some sleep onset insomnia issues going on) now compared to pre cpap?
How are you feeling considering you have trouble getting to sleep which of course is going to affect how you feel during the day.
I realize it is likely less than ideal but wondering if there has been any improvement in general...

Anyone wondering how ugly the Flow limitation graph above is...this is a well controlled boring flow limitation graph.

[oak]

Baseline on Sleep Study: AHI of 46.6, RDI of 49. Lowest o2 saturation 87%. Most were hypopneas and obstructives, not many centrals.

Baseline lateral AHI 51.6 Supine AHI 40.9

sleep efficiency was 63.5%


overall, i have seen a great improvement in daytime alertness (not today however ) i am not afraid to drive anymore
i seem to have a little more energy and a better mood overall

sorry if you asked for anything else and I forgot. not feeling the greatest today.

[Pugsy]

If you were reporting feeling awful..no improvement then the presence of the flow limitations might be significant. They can be a disturbing factor to sleep and thus how we feel.

Looks like your Obstructive Apneas and hyponeas are well prevented at 9 cm...Flow limitations pretty much the same at 9 cm and the maxed out 10 cm apap mode max. Your machine is responding to the Flow limitations most likely...how high it wants to go is anyone's guess...how important it is that it go there...again is anyone's guess. If you told me you felt horrible then we would probably want to try to reduce the Flow limitations to see if that would help but you are reporting feeling a lot better so I don't know if there is much clinical significance to the Flow limitations.

I don't see the increase in pressure being needed as far as the OSA side of things go. Your AHI looks to be roughly 50% central at 9 cm and we know pressure isn't going to reduce those centrals. Trying to eliminate the remaining hyponeas isn't really needed but I don't see the harm in increasing the maximum to see if the FLs reduce and take a few of the hyponeas with them.
You might also consider 8 or 9 minimum in APAP mode and 11 or 12 maximum if you are wanting to maintain a tight apap range.

[oak]

Thanks so much! I think it cant hurt to try 8 cm for the low and 11 for the high pressure for now. Will see if it makes any difference. Thanks to everyone on this forum for all of your help. It is very much appreciated.

[oak]

If you were reporting feeling awful..no improvement then the presence of the flow limitations might be significant. They can be a disturbing factor to sleep and thus how we feel.

Looks like your Obstructive Apneas and hyponeas are well prevented at 9 cm...Flow limitations pretty much the same at 9 cm and the maxed out 10 cm apap mode max. Your machine is responding to the Flow limitations most likely...how high it wants to go is anyone's guess...how important it is that it go there...again is anyone's guess. If you told me you felt horrible then we would probably want to try to reduce the Flow limitations to see if that would help but you are reporting feeling a lot better so I don't know if there is much clinical significance to the Flow limitations.

I don't see the increase in pressure being needed as far as the OSA side of things go. Your AHI looks to be roughly 50% central at 9 cm and we know pressure isn't going to reduce those centrals. Trying to eliminate the remaining hyponeas isn't really needed but I don't see the harm in increasing the maximum to see if the FLs reduce and take a few of the hyponeas with them.
You might also consider 8 or 9 minimum in APAP mode and 11 or 12 maximum if you are wanting to maintain a tight apap range.

okay i have been at 8 minimum and 11 maximum for two nights and i had no osa's and a few hypopneas, mostly all centrals. still, not very many centrals. the flow limitation chart still looks WILD, and the machine stayed nudging at the 11cm mark both nights all night. i dont know if i should increase the max pressure again or just leave it since i dont really understand flow limitations. i mean, i feel good, but i have felt lousy for so long i am not sure i really know what feeling good is like, ya know? is it possible i could feel even better if the flow limitations got under control? ps I am going to see a sleep doctor (finally) in Sept, as I made an appt on my own since no medical person has helped me with this or referred me to a sleep doc. it is not the sleep doc who signed off on my study. my previous doc refused to refer me and anyway i am done with that group.

[oak]

bump

[robysue]

oak,

Sure, you could bump that max pressure up to see if that helps even out the flow limitations. But do keep in mind that sometimes more pressure does not lead to feeling better.

Potential problems with additional pressure include: More problems with leaks and more problems with aerophagia, both of which can play havoc with sleep continuity and how well you feel during the day.

If you wanted to get an idea of just how much pressure might be involved in evening out the flow limitations, you could run your APAP wide open on the upper end for a 2-3 days and see just where the pressure tends to peak out and how much that level of pressure winds up bothering you.

[Pugsy]

Flow limitations are reductions in air flow that don't meet criteria for hyponea or obstructive apnea...
So either not long enough (10 seconds is needed to get a flag) or not enough reduction in air flow.
Obstructive apnea needs a 75% or more reduction.
Hyponea needs a 50% or more reduction.
I suspect that your flow limitations are likely below the 50% threshold. Sometimes high FLs are seen with UARS Upper Airway Resistance Syndrome and sometimes people can have OSA along with UARS and sometimes pressures needed to address the UARS FLs is greater than is needed to address the OSA events. Typically people complained of a lot of arousals with UARS or their sleep studies might mention a lot of arousals. I have no idea if this is what you might have going on...treatment is still cpap/apap therapy though.

I don't know if there is any great clinical significance in your FLs since your AHI is quite acceptable and you are also feeling quite decent.
If you were waking in the middle of the night often then there might be some clinical significance but your main issues appear to be getting to sleep in the first place. Is that correct? And not so much staying asleep???

You aren't having any nasal congestion issues by any chance are you?

If you were feeling horrible and your sleep (once you get to sleep) was fragmented...then we might want to see if things would improve by using more pressure to see if the FLs reduce but since you aren't complaining of those problems and actually feel like you are improving quite a bit then I don't know how critical it is to zap those FLs.
As Robysue says...increasing the max could open up a whole new set of possible problems...or it might not.
I run my machine wide open an just the other night I saw it hit 20 cm...I never knew it though...no aerophagia...no waking up with hurricane force winds and the only way I knew it happened was the report the next day.

Since you are new and don't quite understand what you are seeing right now there is no urgent need to do anything at the moment.
At some point you might understand things enough that you are more comfortable with a larger range in pressures and you might try it later if you want to. You don't have to do everything right now...you have lots of time for experimenting.