Thanks, all, and the next steps...

First: A big THANK YOU to all the regulars (and not-so-regulars) who've donated their experiences and advice here. Since my MD first suspected sleep apnea, I've been reading everything I can, and this forum (and its related sites) has the best information on the web. I knew what to expect from my sleep studies, what the results meant, how to choose a sleep doc, and how to deal with a DME (and WIN!).

Really, you all are lifesavers - literally.

So, I've been set up for a few months, and the equipment side of things is good. CPAP has become second nature to me.

However, I'm still getting sleepiness during the day. It's been about five months, at a pressure of 8. The pressure was based on an all-night titration study, after the diagnostic gave me an AHI of around 9. Not as high as a lot in this forum, I know, but I was falling asleep at stoplights, so it was definitely having an impact.

After all this time with the card and software to keep up on, I'm coming up on my first follow-up with the sleep MD after a few months. I've been averaging an AHI of about 3.4 over all that time - lately it's been a little higher - sometimes as high as 4.

I know this is borderline to even get the diagnosis, but I'm still having symptoms, and I'm concerned that the pressure's not right. My plan is to ask the doc to prescribe an APAP range. (Getting an APAP machine for a CPAP prescription from a greedy DME was quite an experience, but is another story...)

When we originally discussed it, the attitude of the MD was "for APAP, I'd just set it at 4 to 20 and see what the machine does." Based on feedback I hear here, and what I know of the machine, I don't think that's necessarily prudent.

I'm planning to propose a range, but I'd like to have some kind of justification for it, and I'd like it to be a lot narrower than 4-20.

Any thoughts or suggestions for a reasonable range, with some thought toward justifications I can provide to the MD? He's been great, so I'm sure we'll come to a meeting of the minds, but - as for all things medical - I know I have to be my own advocate, and I want to be armed with all the information I can get.

Any thoughts from the older, wiser hoseheads out there?

Thanks in Advance,
HoseHeadDaddy

I'm confused about what your machine pressure setting(s) is/are.

Is your machine in a range of 4 - 20 or set to single pressure of 8?

Your profile shows that you have the Encore Pro software. You should have been able to get some ideas from the daily details reports as to your pressure settings.
Whatever the setting, it seems apparent that you need more pressure to prevent the events from occurring.


Den

How about 8 to 12, and see how that goes for a week? It'll start where you are now, but give you more scope, and is a fairly standard mid range spread.

8 - 12 would be fine.

I'd want more unused ceiling up above. I'd set it at 7 - 20, then do a download after no more than 3 nights to see how the machine was behaving.

The important number to get set right in the range, imho, is the bottom pressure. I think the minimum pressure in the range needs to be set at, or fairly close under, the prescribed pressure.

With a prescribed pressure of 8 , I'd want to set the minimum pressure of an autopap at 6, 7, or 8.

The top pressure can be way up there and it won't matter. The higher pressures that are available but not used are just that...not used. So, it doesn't matter that they are "there."

There are two reasons why I like to keep the top pressure set high ( 20 ) with an autopap. Several clues it can give me if the autopap does run up quite a bit higher than expected:

1. I'd take a serious look at leaks. Mask leaks. Or mouth leaks/mouth breathing, if not using a full face mask to cover nose and mouth.

2. If leaks were well under control, I'd think VERY seriously about GERD (acid reflux...and it could be completely asymptomatic, called "Silent GERD") as a possible interference with good cpap treatment.

3. If using a Puritan Bennett 420E autopap, extreme pressure run-ups can be an indication that the default setting of FL On (IFL1 on) should be turned off.

Of course, all this detective work is dependent on being able to use software to see the detailed data from an autopap. In particular, getting a thoroughly detailed look at the leak rate graph for the night via software rather than just seeing a leak average on the LCD of some machines.

I'd choose to use a Respironics autopap since they are coming out soon with software for patients to do their own Smart Card downloads at home, if they wish:

Sep 10, 2007 subject: Respironics - Encore Viewer will be available in October(?)
viewtopic.php?t=24039

Note Titrator's post on page 2 of that thread. Good news, indeed!

Or, I'd use a Puritan Bennett 420E autopap since they have never put a restriction on who can buy their software (Silverlining.)

Thanks, all... Wulf, my current pressure is a constant 8.

rested gal wrote:8 - 12 would be fine.

I'd want more unused ceiling up above. I'd set it at 7 - 20, then do a download after no more than 3 nights to see how the machine was behaving.

Good-sounding advice, with great rationale. I've been nervous about having the top end set too high (irrational fear?), but you provide some great points as to how that could help diagnostically.

rested gal wrote:Of course, all this detective work is dependent on being able to use software to see the detailed data from an autopap. In particular, getting a thoroughly detailed look at the leak rate graph for the night via software rather than just seeing a leak average on the LCD of some machines.

I'm right with you: I have Encore Pro and EPA and have detailed data for all but the first month or so of therapy. Reviewing leak rates and resulting AHIs motivated me to ditch the Swift II - my previous alternate-night mask.

rested gal wrote:Or, I'd use a Puritan Bennett 420E autopap since they have never put a restriction on who can buy their software (Silverlining.)

Yeah, I managed to get the software before they really cracked down entirely, but it wasn't all that easy. The profit margins and senseless waste surrounding this condition (OK - perhaps the whole healthcare system in the U.S.) has been the most frustrating part of the experience for me. The greed of some parts of the supply chain (*cough* DMEs *cough*) coupled with the incompetence/collusion of the insurance industry (no, we don't want to save $1000 on the cost of the machine) is amazing.

Thanks again for all your help and advice!

-HHD