Need Suggestions for Interpreting & Adjusting Settings

Ten months ago today I got my CPAP. For the 1st 6 months it was a real struggle, altho' I did see improvements, like not being so tired during the day, not getting up so much during the night, etc. Then it was suddenly not such a constant battle anymore, but still not "perfect" by any stretch. I had a lot of questions about who was in charge of what . . . doctor, DME, Respironics. Here, & elsewhere, I've since learned that the person responsible is me.

A month ago my doctor changed my pressure from 8 to 11; constant. That was after an appointment that I requested to discuss my AHI ranging for the previous month from 1.5 to 10.1 (avg 5.2) & MaskFit averaging 99.5%. I wanted to better understand the meanings & relationship of these numbers. I learned a lot that day . . . mostly, that my doctor seems to know little about how CPAP machines actually work. The change of pressure, I think, was mostly to give the appearance of "doing something".

With a constant pressure of 11 my AHI ranged from 0.5 to 6.6 (avg 2.1), but MaskFit ranged all the way from 5% to 100% (avg 77.7%). And I had bad dry mouth & sore throat some mornings.

Three nights ago, for the 1st time, I changed the settings myself. I had been told by doctor that I couldn't do that. I lowered the pressure to 10, hoping the mask fit would improve w/o damaging my AHI numbers. The 1st night seemed to indicate that maybe that was a step in the right direction. But for the 2nd night AHI jumped all the way up to 20.3 (by far my worst ever), because Obstructive Apneas jumped up to 121 (by far my worst ever). I have no idea what caused the drastic jump. Last night's numbers looked better.

I've noticed via SleepyHead that my pressure settings were changed (after a 3 month trial that I wasn't told about) from variable (6-12) to fixed (8 then 11). Logic tells me that (possibly with adjusted min & max) variable pressure would make more sense than an arbitrary number picked by my doctor. After all, the doctor's guess is (supposedly) based, at least partly, on numbers provided by the same machine that will be making the real time variable pressure decisions.

I know that 3 nights is insufficient to indicate a trend, but I'd appreciate any comments & strategies for tweaking settings.

I can see why you're feeling frustrated.

On that really nasty night, all the OAs are confined to really bad clusters of events followed by some extended time between the clusters that is relatively event free. On the nights with lower AHI, there are still some evidence of clusters of events.

I wonder if your OSA is highly correlated with being in REM and/or sleeping on your back. Do you know if your diagnostic study showed that your OSA is much worse in REM? Or whether it showed that your OSA is much worse when sleeping on your back? I also wonder what the 90% pressure level was back when you were using the machine in APAP mode.

As for what to do: You could try switching to APAP. I'd suggest that the min pressure for an APAP range ought to be around 10 for you. Anything less than that is not going to deal with those nasty clusters. But as the pressures rise in response to those clusters, you may very well have some serious leaking.

You say that the 'mask fit" numbers (coming from SleepMaster??) have decreased, and sometimes decreased significantly, since the doc upped your pressure to 8cm Could you tell us what kind of mask you are using so that we can figure out what, if anything, the leak graphs are telling us?

robysue wrote:As for what to do: You could try switching to APAP. I'd suggest that the min pressure for an APAP range ought to be around 10 for you. Anything less than that is not going to deal with those nasty clusters. But as the pressures rise in response to those clusters, you may very well have some serious leaking.

I made the same suggestion in his other thread.

robysue wrote: I wonder if your OSA is highly correlated with being in REM and/or sleeping on your back. Do you know if your diagnostic study showed that your OSA is much worse in REM? Or whether it showed that your OSA is much worse when sleeping on your back?

Yes, I've developed the habit of sleeping on my back . . . doctor's orders (30 years ago) because of achalasia (related to reflux/GERD). The head of my bed is on 4" blocks & I use several pillows. I've been "learning" all over again to sleep on my side since my OSA diagnosis. I usually go to sleep quickly & on my back. I almost always wake up on my back.
My (2-11-14) Polysomnography Report's Respiratory summary said "During NREM and REM sleep on the side, there was mild sleep apnea whereas during supine sleep obstructive sleep apnea became moderately severe. There were burst of snoring at intervals. The apnea-hypopnea index was 17.3/hr. The respiratory disturbance index overall was 21.4/hr. Approximately 260.5 min was spent asleep in supine position. There was moderate oxygen desaturation during sleep: the mean oxygen saturation was 94% with the lowest recorded of 83%."

robysue wrote: I also wonder what the 90% pressure level was back when you were using the machine in APAP mode.

I don't know what 90% level means. Is that the top line in the Leak Rate graph? SleepyHead has all my data from the beginning. Can I go back & look? SleepyHead has a "jump to latest date" arrow . . . too bad there's no "jump to 1st date arrow". Maybe these stats will help.

robysue wrote: As for what to do: You could try switching to APAP. I'd suggest that the min pressure for an APAP range ought to be around 10 for you. Anything less than that is not going to deal with those nasty clusters. But as the pressures rise in response to those clusters, you may very well have some serious leaking.

What max pressure do you recommend? A few days with variable pressure before my doctor's appt next Friday might provide some talking points.

robysue wrote: You say that the 'mask fit" numbers (coming from SleepMaster??) have decreased, and sometimes decreased significantly, since the doc upped your pressure to 8cm Could you tell us what kind of mask you are using so that we can figure out what, if anything, the leak graphs are telling us?

Pressure was upped FROM 8cm to 11cm. I have a S&P Simpus Full Face Mask. I also have a short full face beard that I know has a bearing of mask fit. For a couple of months before the pressure increase mask fit was almost always 100%. After pressure increase, I've trimmed it even shorter, which seems to help a little. I also use saline spray before bedtime, Breathe Right strips and a chinstrap (outside of headgear).

Robear wrote:

robysue wrote: As for what to do: You could try switching to APAP. I'd suggest that the min pressure for an APAP range ought to be around 10 for you. Anything less than that is not going to deal with those nasty clusters. But as the pressures rise in response to those clusters, you may very well have some serious leaking.

What max pressure do you recommend? A few days with variable pressure before my doctor's appt next Friday might provide some talking points.

the quickest way to see what you might need is to set max at 20 and sleep with it. it generally won't go higher than needed.

robysue wrote: I also wonder what the 90% pressure level was back when you were using the machine in APAP mode.?

here ya go:[url=http://imgur.com/VTrbqAd.png][/url
it looks really nasty, and is, pressure never increasing enough to prevent the hypopneas, because the leaks were so bad the machine wouldn't increase the pressure, except on rare occasions.

I wonder if all that back sleeping, esp. on blocks, has caused your head to fall forward when sleeping, cutting off your airway. Many people find that using a soft cervical collar helps to fix that - keeps your head up, jaw closed and airway open. Might be worth a try I think.

Julie wrote:I wonder if all that back sleeping, esp. on blocks, has caused your head to fall forward when sleeping, cutting off your airway. Many people find that using a soft cervical collar helps to fix that - keeps your head up, jaw closed and airway open. Might be worth a try I think.

Thanks for the suggestion. Actually, a cervical collar has also become part of my arsenal. I used it for a 10 day period, ending 10 days ago. During that time AHI ranged from 0.6 to 6.6 (avg 2.3) & Mask Fit ranged from 67 to 100 (avg 91). That was while I waited for a chinstrap to arrive (in Maryland; from Utah or NM). The strap has proved to be less useful than expected. I might go back to the collar.

I changed my pressure settings last night from constant 10cm to A-Flex (10-20). I really don't know/understand the difference between A-Flex and C-Flex (or C-Flex+), so my decision was solely because that was the mode 1st set when I got my cpap & I wouldn't be going into complete virgin territory (for me). Altho' there were a number of problems way back then, I don't think any were "flex" related. I set A-Flex X2 just for a middle of the road approach. I might up that to 3 tonight or maybe wait another night so that I'll have more than a 1-night test. Overall, I think the change was positive. The only negative that I noticed was that when exhaling, my breath seemed rather warm. I remember that in the weeks/months after 1st starting cpap, hot breath was particularly bothersome for me. I have become accustomed to the pleasing cool "inhale air" (especially when 1st turned on), which I *think* might have been a little warmer last night. Humidifier settings remained at 3. Altho' ramp is set for 20 minutes, I don't think it has ever happened.

I woke up briefly several times &, except for 4am when it took longer, each time I went right back to sleep. I also used my cervical collar instead of chinstrap & tried to sleep on my side more.

Robear wrote:I really don't know/understand the difference between A-Flex and C-Flex (or C-Flex+), so my decision was solely because that was the mode 1st set when I got my cpap & I wouldn't be going into complete virgin territory (for me). Altho' there were a number of problems way back then, I don't think any were "flex" related. I set A-Flex X2 just for a middle of the road approach.

there's really no fundamental difference in any of the flexes, respironics loves 'em for marketing, which is why they slather *flex all over everything... it's like saying "ford f150 WITH TIRES!!!" all the *flex things basically just give a little pressure relief as you start to exhale.. there may be some technical difference between c, c+, a, bi, but they're all handwavey and smoke and mirrors and LOOK SQUIRREL! and change the subject. theres no right or wrong to *flex, it's purely supposed to help the 'comfort' level.

Robear wrote:The only negative that I noticed was that when exhaling, my breath seemed rather warm. I remember that in the weeks/months after 1st starting cpap, hot breath was particularly bothersome for me. I have become accustomed to the pleasing cool "inhale air" (especially when 1st turned on), which I *think* might have been a little warmer last night. Humidifier settings remained at 3. .

puzzling, since raising the pressure would flush out your breath faster... and shouldn't have any noticeable affect on the humidity.

My doctor told me (several times) that I could only change the humidity & ramp settings . . . that I couldn't change any other settings. I didn't know any better, so I believed her. Whenever her "prescription" changed, her office notified the DME, who made the changes remotely. Sometimes that took several days.

That's not so important to me now that I've learned to change settings myself....with or without her knowledge or approval. Theoretically, she could disagree & have the DME change them back without telling me about it.

I don't want that to happen. I want to know whenever changes are made. Is there a way to "lock" settings to prevent them from being changed remotely? Or to notify me somehow that changes have been made?

Robear wrote:My doctor told me (several times) that I could only change the humidity & ramp settings . . . that I couldn't change any other settings. I didn't know any better, so I believed her. Whenever her "prescription" changed, her office notified the DME, who made the changes remotely. Sometimes that took several days.

That's not so important to me now that I've learned to change settings myself....with or without her knowledge or approval. Theoretically, she could disagree & have the DME change them back without telling me about it.

I don't want that to happen. I want to know whenever changes are made. Is there a way to "lock" settings to prevent them from being changed remotely? Or to notify me somehow that changes have been made?

there's no way to lock the settings on a machine.

you could take the modem off.

you can also tell them you do not consent to their changing the pressures, it IS your machine after all.