Going on the hose without sleepstudy with Intellipap Auto

You're right of cause, it will take time to get used to all this. I will just leave my pressures set at 6-18 and collect all the data I can, both from the machine and O2 saturation. At least I will have a much easier time getting used to the machine when I can go to sleep with such a comfortable low pressure.

Does anybody have information or links concerning what is the best way to use an APAP? I'm thinking about wide or narrow pressure ranges. I would be very interested to read more about this, before making my own decitions later on.

I wish you all a Merry Christmas!
I'm certainly enjoying my gift to myself, which is giving me the beste sleep I have ever had.
I'm very grateful for finding this forum and all the help I have received.

Burkebang wrote:Does anybody have information or links concerning what is the best way to use an APAP? I'm thinking about wide or narrow pressure ranges. I would be very interested to read more about this, before making my own decitions later on.

There has been lots of discussion about pressure ranges wide vs narrow but I have one link saved that may be interesting for you. viewtopic.php?f=1&t=39869&st=0&sk=t&sd=a

If pressure changes do not disturb your sleep then there is no reason not to have a wider range because the machine won't go anywhere it doesn't think it needs to go. If pressure changes seem to cause sleep disruptions then by all means...limit the range to limit the changes.

It is the minimum pressure that is most critical. This is because these APAP machines don't raise that minimum very fast in response to events. Instead they go up rather slowly and in stages. If they start out to low then it takes too long for the pressure to get to where the events would be better prevented and the events happen and go away all before the machine can get the pressure up high enough.

So your minimum of 6 cm is just not enough to give the machine a good enough head start. The machine can't respond in a timely fashion to events that need say 10 cm to prevent airway collapse.

I found this out myself back when I started therapy. With minimum of 8 and (maximum of 20) my AHI was running around 10... increasing the minimum to 9 reduced the AHI to around 7.....minimum of 9.5 gave me AHI around 5....minimum of 10 gave me AHI less than 3 and I finally felt better.
Finally settled on 10 to 20 range. My overall average over months and months was 12...some nights I had a few spikes to 18 (super strong stubborn REM events)...but overall average is right around 12.

If 9 cm minimum isn't comfortable for you....then go up in stages and it will be much easier to get there.
Wide range is okay...but that minimum pressure is the most critical one and you really need it higher than 6 to give the machine a good head start on preventing the events that need 12 cm.

Pugsy, thank you very much for your post. This was excactly what I wanted to read about.

The conclusion I draw from the reading I have done is that people are different and machines are different. The only thing to do is to do a lot of testing and find out what works for me. But there are some things worth thinking about. Like noice. Last night I had my machine at 5-18. At 5 there is very little noice from either machine, hose or mask. Breathing feels very natural, like without the machine. This meant that I had no problem going to sleep and sleep uninterupted all night. When my GF moves in with me, she also will have no problem going to sleep. My GF has wonderful sleepquality and I would not want my problem to compromise her sleepquality.

I had a moderate amount of alcohol last night. Before, this would have meant that I would have snored insanely all night and I would have woke up feeling like I had been run over by a car(repeatedly). But now I had a wonderful nights sleep and feel really great this morning. My 90/95% pressures was actually low, 8/8.5. AHI was just 4,5 with no dips in SPO2 at all. This means that all event was dealt with perfectly by the machine, even with such a low lowpressure.

I read how machines go "bananas" and overcompensates by pushing the pressures much higher than needed, I also read about machines varying the pressures so briskly and frequently that it wakes the user. All this would be very good reasons to up the lowpressure to a level that would stop the machine from actually doing much automatic regulation at all.
My Devilbiss has none of these problems on me. I'm starting to believe what I have read about Devilbiss having a fantastic algorithm for their automatics. Even though it's not as complicated or good at distinguishing the different types of apneas as others, it definatly works very well in practise.

It seems like I am also very lucky with my throat. I used my Flexset nasal mask last night and I have no mouth leaks at all. When I get pressure through my nose, my mouth closes of so well that I have to use quite an effort to open the airway and create a mouthleak.

I know I am extremely lucky to have such a easy time adjusting to CPAP treatment. Also, the time I spent on research before deciding on which machine and masks to buy, have really payed off bigtime for me. Bad masks and a "hyper" machine would have given me a much harder time adjusting to treatment.

Burkebang wrote: I read how machines go "bananas" and overcompensates by pushing the pressures much higher than needed, I also read about machines varying the pressures so briskly and frequently that it wakes the user

Runaway pressure increases most often are from leaks. The machine doesn't increase pressures willy nilly without some sort of reason (even if wrong). I experienced it one time. I have documented it here along with the probable cause. This night is pretty much the only night where higher pressure variations bothered me. This night had highly fragmented sleep. Easy to see where things went bad.
viewtopic.php?f=1&t=67883&p=631376&hili ... mb#p631376

If you sleep well and feel well rested, then that is what matters above anything else.
If the minimum of 5 gives you this well rested feeling and continues to have a downward trend in AHI, then by all means use it. Wait until you have a night, without alcohol involved though, to base your ideas. When alcohol is involved it can mess with sleep stages and can mess with your reports.
Devilbiss says AHI of under 10 is acceptable....I personally feel AHI under 5 is a better acceptable goal.

Give things some time to settle in. It does help.

Burkebang wrote:It is also really important that I get my energy back now, as I am about to become a father.

Congratulations !

My doctor did not know where to start me, so he prescribed 5-15 on auto, which turned out to be correct.

Thank you Maxdarkside:-)
I'm starting to believe that 5-15 or 5-max is correct for most people.

I'm trying to really understand what the sleep data I get means. I'm more or less on my own with my treatment and even with the help of all you wonderful people in this forum, it's important to me to really understand what's going on, myself. I've gotten a bit stuck in comparing APAP and CPAP. This is the way I understand it:

When your CPAP machine reports your AHI as say 8. That would mean that you had an average of 8 uncontrolled breath events pr. hour, that the machine could not help to resolve. All events that where avoided because of the CPAP pressure, will not be detected and scored in the AHI. The unresolvable and recorded AHI events could send your O2 saturation very low, as the machine works at a constant pressure, which is not high enough to prevent these apneas from happening. So a high AHI is/can be very bad for a CPAP user and a low AHI is a good meassure of the quality of the therapy.

My APAP showed me a AHI of 8,5 this morning and I felt great. A look at the Oximetry report showed that allthough I had events, they where ALL dealt with by my machine. I had just 23 O2 events ALL night and 94% was the lowest recorded level. Since I got my APAP, my basal O2 level has gone up from 95'ish to 97'ish because of the air blowing into my lungs, so none of these events would even have been "scored" as an event before, without the APAP running and boosting my basal level. When I look at it like this, concerning my O2 levels, I'm actually getting 100% effective therapy, even if my AHI is 8,5.

If my understanding is correct, an AHI report from an APAP machine is really worth little or nothing without being compared to an O2 report. The lower you set the lowpressure, the more events will be recorded as events, before being resolved without them ever causing any healthproblem. Theoretically I could have an AHI of 50, but as long as none of the events wakes me up or send my O2 below 94%, the therapy would still have to be considered 100% successful.

Am I correct in my understandings? Or am I missing something?

If I'm correct, then I read about how many people are using their APAPS with high lowpressures and with narrow pressureranges, to reduce AHI. Then I believe these people are not taking advantage of their machines, they are using them as simple CPAPS, with the added benefit of being able to control events requireing pressureextremes to control, that is as long as they have not set their highpressures too low. They will of cause get the benefit of controlling their apneas. But the extremes will be scored as apneas and increase the AHI. If their main goal is to have the lowest possible AHI, it can lead to them upping their lowpressures to levels that are way higher than needed. This will also make using/getting used to the machine a nightmare (compared to my own experiences), will needlessly cause problems with aerophagia, skinproblems caused by very tight headgear and masks etc. etc.

I see that my 90/95 percentile pressures vary a lot from night to night, so far from 8 to allmost 15. If I had a titrationstudy on a 8 night, I would get very bad therapy with a CPAP set at 8. If I had the study at a 15 night, I'd have very low AHI's, but I'd have to sleep in a mostly unneeded hurricane every night to get that result.
With my APAP, I go to sleep in extreme comfort. I'm getting the excact pressures I need to keep my airways open THAT night, avoiding most if not all problems and discomfort that constant high pressures (can) give.
But most importantly, I actually get 100% effective therapy.

I think an AHI of 8 is good if you had much higher in your sleep study and eliminated the bulk of them at the start. Over time, as you adjust to the machine, yours may go lower as mine did (see below, last night being around 0.75 (woot!)). You can see I started around AHI of 6 on the machine (sleep study was 24 non-REM, 48 REM AHI's):





Also, with an auto machine, I believe it's good to let it do its magical work, reducing pressure when it is OK to so you are *not* gulping a hurricane, but boosting pressure when needed. Here's a picture of last night, with the machine fluctuating between 5 and 15 (limits) but you can see it didn't get much above 12, so I may drop the 15 max just for an experiment, because when and if it does get around 12-15 I end up arousing (too much for me!).



You can also see near the right end of the chart, there are increases in mask pressure made by the machine even though no apneas were scored. My (different than yours) machine detected one occurring and boosted the pressure, tho it was not long enough to be "scored".

Really great graphs you have there, is that from Sleepyhead?
When you have a history of such graphs to look at, making good decitions about your treatment must get much easier. Do your pressure needs vary from day to day?
Do you have a recording pulseoximeter? I'd be really interested in hearing about your O2 reports also.

I'm really looking forward to my Smartlink module arriving:-)

Burkebang wrote:Really great graphs you have there, is that from Sleepyhead?

Yes.

When you have a history of such graphs to look at, making good decitions about your treatment must get much easier. Do your pressure needs vary from day to day?

It does help to see what is going on, longer term, over a night and also zooming in on events to understand. I do go up towards 15 cmH2O at times, particularly when the machine finds 30-40 second apneas. It seems to get excited about those and gets aggressive in trying to blow them away, so to speak. I then awaken to what is, for me, over-pressure.

Do you have a recording pulseoximeter? I'd be really interested in hearing about your O2 reports also.

Yes, I have a CMS-50E "finger burner" with recording. I would say my sats are rarely going into the 80s. Most always 94 or higher. My sleep study minimum was 79%. My HR trace looks correlated a lot with the "Resp. Rate", "Tidal" and "Minute Vent" charts in SleepyHead. I can see REMs in the O2 and HR (CMS-50E) that match up with the respiration related trend plots in SleepyHead.

Thanks.

Different people have different needs. There are a lot of things to fool with to adjust to CPAP and find the "right" pressure.

However, I think the most generic good practice is to set the minimum pressure to something that eliminates most of your apneas, and the machine stays at that pressure most of the night. Set the maximum pressure to something that's enough higher that it doesn't auto to the limit. Turn off exhale relief and ramp.

Adjust from there if necessary.

Ramp or exhale relief may help newbies. Taper off them if you can do so comfortably.

If the pressure tends to run away or cause centrals, reduce the maximum pressure. Some people may benefit from a lower minimum pressure and letting the machine auto up if necessary.

Check the results regularly and find out what works for you.

Burkebang,

Many thanks for your original post -- especially the title. I have had a couple of sleep studies in the past, but no current prescription for machine or pressures. Bought a machine, and now I am trying to learn how to use it. The sequence of responses your post has drawn is the best reading I have found so far.

All The Best,
Bob and Ray

I am a complete newbee and I don't know what I will do after I get more experience and get more used to using my machine. For now, I trust my machine to automatically control my therapy and I give it unlimited control to do that. I monitor the quality of the therapy I receive every night with my pulseoximeter, to make sure that the machine is able to keep my saturation at healthy levels.

When it comes to the pressure range settings, I get the feeling that people look way to hard at the AHI numbers that the machine reports. The only thing that makes sleepapnea bad for our health, is oxygendepravation during long apneas, which leads to severe drops in our bloods oxygen saturation. There is no healthrisk for a normal otherwise healthy adult person in not breathing for 10 seconds, while an APAP adjusts its pressure to reopen the airways. It certainly does not lead to any SPO2 level drops for me. I'm quickly loosing interest in the data reported by the machine, what's important to me is the Oximetry reports from my pulseoximeter, that is the ultimate way to meassure the effect of my therapy. The only night I have gotten less than perfect therapy, was my first night, when I had my highpressure limited to 15. That caused the machine to not be able to respond properly to an event and I had my saturation drop quite low.

I absolutely love the Smartflex function of my machine, I cannot ever see me turning that off. I see absolutely no advantage in doing that. Maybe other machinetypes do not have such a good exhale relief function, but the Devilbiss' Smartflex is just wonderful. At my low pressure of 5 cm H2O, I really don't need Smartflex, but having it on is still better than turning it off. But my machine is normally running somewhere between 8-14 cm H2O while I sleep and at those pressures, the 2 cm H2O (max 3) that the Smartflex saves me when exhaling, I believe gives me considerably better sleep quality and makes me able to accept higher pressures without waking up.

I see no reason to use ramp with an automatic machine. The only thing the rampfunction does, is to prevent the machine from responding to events for a set time. Ramp would be a very nessecary funtion for streight constant pressure CPAP use, but with an automatic CPAP, setting the lowpressure to the most comfortable "ramp level" I have found, really makes the function obsolete.

I have read a lot of horrorstorys about people struggeling to get used to their CPAP machines, many have given up. Since I got the machine, I have slept between 6 and 8 hours on the machine EVERY night, all my sleeping has been on the machine and I feel much better in the mornings, right from day 1. I feel that my body is slowly starting the recovery process after at least 15 years of severe nightly oxygendepravation.

If I had waited for a sleepstudy and had been sent home with a constant pressure CPAP set at or above 10, I most likely would not have been able to get used to that... My APAP shows me that to be effective, my constant CPAP pressure would have to be 15. I DEFINATLY would not have been able to get used to that, this much I know now.
I'm so happy that I went out on the internet to look for help, in stead of just waiting for a sleepstudy and accepting the gear that they would have given me, which would most likely have been a streight CPAP here in Norway.

Thanks to the internet and mostly the wonderful members of this forum, I am going to sleep at night with a completely silent bedroom, due to some great advice I found on noice reduction. I breath warm and moist air without rainouts, due to the advice I found on using heat cables for reptiles inside my hosecosy. Other advice led me to try controling the heat cable with a rheostat, that gave me the ability to match the air temperature in the air from the hose, to that of just breathing the room air. This improved my comfortlevel even further and lowered the temperature of the heat cable to a level that it is merely luke warm, so if the heat cable gets rolled up on itself or gets stuck under my pillow or bedcover, there is no risk of meltdown and fire.

As thanks for all the great advice I have gotten, I try to document my experiences in the hope that they may be useful for somebody who is in the same situation as I was in. Starting CPAP treatment on your own is no problem at all and can be done effectively and comfortably, specially when you have the great support of this forum and can take advantage of all the practical user experience found here or offered to you so generously upon demand. So I wish you good luck Bob and Ray, if you have any questions, you'll get all the help you'll need here. Please document your experiences so others can take advantage of your experiences.

Hopefully I can also try to influence some of the more experienced users to turn their attention more toward their Oximetry, than their AHI's and widen up those auto ranges

When googling, I found this article, that may be of interest.

Burkebang wrote:When it comes to the pressure range settings, I get the feeling that people look way to hard at the AHI numbers that the machine reports. The only thing that makes sleepapnea bad for our health, is oxygendepravation during long apneas, which leads to severe drops in our bloods oxygen saturation. There is no healthrisk for a normal otherwise healthy adult person in not breathing for 10 seconds, while an APAP adjusts its pressure to reopen the airways. It certainly does not lead to any SPO2 level drops for me. I'm quickly loosing interest in the data reported by the machine, what's important to me is the Oximetry reports from my pulseoximeter, that is the ultimate way to meassure the effect of my therapy.

It is good if your oxygen concentration doesn't drop. However, even if your oxygen doesn't drop, there can be serious health problems.

Apnea can cause sleep disturbance even without oxygen deprivation. This can seriously affect your brain and overall health.

If apnea cuts off your airway, this can cause stress. The stress can be harmful to your health in many ways.

Burkebang wrote:I absolutely love the Smartflex function of my machine, I cannot ever see me turning that off.

I use a pressure of 14. After adjusting to it, I can't even feel it. I sometimes have to convince myself the machine is blowing air by putting my hand over the vent on my mask. Flex does nothing for me any more. The flex/exhale relief pressure changes can cause your mask to move around as pressure goes up and down and this can affect fit and leaks. It may make the machine noise more noticeable.

I think if you turn flex off, you won't notice after a few days. I recommend people turn it of and try it for a while once they're used to the machine.

However, if you find you breathe better with flex after trying it without flex, use it. Some people think it helps with gas, some don't.

Burkebang wrote:I see no reason to use ramp with an automatic machine. The only thing the rampfunction does, is to prevent the machine from responding to events for a set time. Ramp would be a very nessecary funtion for streight constant pressure CPAP use, but with an automatic CPAP, setting the lowpressure to the most comfortable "ramp level" I have found, really makes the function obsolete.

I say the only reason to use ramp on any machine is to make it easier to fall asleep for those who aren't used to the pressure. If they work at it, after time, most people will become used to full pressure and not need ramp. Ramp is mostly for newbies. If you use ramp, it's harder to get your mask to fit right because it may leak after pressure rises.

For an auto machine, I think the lower pressure should be set high enough to give you good therapy most nights without increasing pressure. Machines don't adjust instantly to apneas. If your lower pressure isn't high enough, you may suffer from some breathing problems until the machine adjusts up to the correct pressure. You may spend the whole night having some breathing restrictions on and off, when raising the lower pressure setting would let you breathe right for more of the night.

Setting your lower pressure too low generates many of the same problems that ramp does, although the machine may correct it faster on auto than it does on ramp.

Burkebang wrote:I have read a lot of horrorstorys about people struggeling to get used to their CPAP machines, many have given up. Since I got the machine, I have slept between 6 and 8 hours on the machine EVERY night, all my sleeping has been on the machine and I feel much better in the mornings, right from day 1. I feel that my body is slowly starting the recovery process after at least 15 years of severe nightly oxygendepravation.

If I had waited for a sleepstudy and had been sent home with a constant pressure CPAP set at or above 10, I most likely would not have been able to get used to that... My APAP shows me that to be effective, my constant CPAP pressure would have to be 15. I DEFINATLY would not have been able to get used to that, this much I know now.

Not everyone adjusts as well as you did to an untitrated APAP. There are horror stories there, too.

Lots of people don't adjust well to a manual CPAP set by an in-lab sleep study, either. Especially if nobody looks at the data and adjusts the pressure to find the right combination.

The important this is whether your therapy works for you.