APAP adjustments

DreamDiver · Post by **DreamDiver** » Mon Apr 27, 2020 3:17 pm

milboltnut wrote: ↑
Mon Apr 27, 2020 3:03 pm
Ok so.... as I increase the start pressure gradually the max pressure will gradually increase?

Sorry for the confusion.
There are two clinical pressure settings on your machine: Min pressure and Max Pressure
These only change when we change them. They cannot change on their own.

There is one patient-available pressure setting: EPR or Flex. You can change that from 0 to 3.

There are statistical readings available on OSCAR in the stats sidebar that include:
pressure readings: min, median, 95% and max.
These change nightly depending on how you breathed.
Min is the minimum pressure all night. Max is the maximum pressure achieved all night. Median is were about half of the pressure readings fell all night. 95% is an indicator of how most of your pressures were under this number all night. If you had a few pressure-sensitive event flags, you might see your pressure go up. The max for one night might be 10.5. For another night it might be 12.0. It all depends on how many pressure-worthy events and how quickly in succession they come.

That said, if you change your max setting to 12 cm, even if you need more pressure, you will never go over 12 cm. It will just skud along the top of your graph around 12cm.

If you never had any events that change pressure, your pressure would remain all night at your minimum pressure. If your minimum pressure was set to 6 with an AHI of 0 all night, most likely your other pressure stats would also all show 6 for that night. Meaning you never changed from pressure 6cm all night. Min, median, 95% and max would all read "6.0cm". Make sense?

milboltnut · Post by **milboltnut** » Mon Apr 27, 2020 3:25 pm

most of it yes.....

However, The screen I see is this...

"sample therapy sub menu"

https://www.apneaboard.com/dreamstation ... structions

what do I have to adjust? hopefully I can get an APAP

DreamDiver · Post by **DreamDiver** » Mon Apr 27, 2020 4:36 pm

milboltnut wrote: ↑
Mon Apr 27, 2020 3:25 pm
most of it yes.....

However, The screen I see is this...

"sample therapy sub menu"

https://www.apneaboard.com/dreamstation ... structions

what do I have to adjust? hopefully I can get an APAP

From your profile it says you have a straight CPAP machine. However, when I look at an image you posted, it says APAP, but that you have your APAP set to CPAP mode. You need to set your machine to APAP mode, and then the Min and Max settings will appear.

Unfortunately, I don't have this machine, so it may help for someone else to offer you guidance on this.
It's probably good if you will change your profile so that it's actually APAP, unless OSCAR is misreading your machine, in which case, that's a bug in OSCAR. I'm curious what the outcome will be for this.

Chris

milboltnut · Post by **milboltnut** » Mon Apr 27, 2020 4:46 pm

Gee Chris.... guess that explains the rise in pressure.

It is a auto CPAP.....who's the go to person for auto cpap?

DreamDiver · Post by **DreamDiver** » Mon Apr 27, 2020 4:49 pm

milboltnut wrote: ↑
Mon Apr 27, 2020 4:46 pm
Gee Chris.... guess that explains the rise in pressure.

It is a auto CPAP

I must be tired... I'm looking at it again, and your graph says it's set to APAP mode. I think I better call it for today.
Apologies.

Chris

milboltnut · Post by **milboltnut** » Mon Apr 27, 2020 4:51 pm

DreamDiver wrote: ↑
Mon Apr 27, 2020 4:49 pm

milboltnut wrote: ↑
Mon Apr 27, 2020 4:46 pm
Gee Chris.... guess that explains the rise in pressure.

It is a auto CPAP
I must be tired... I'm looking at it again, and your graph says it's set to APAP mode. I think I better call it for today.
Apologies.

Chris

no it says PAP mode: auto cpap

milboltnut · Post by **milboltnut** » Mon Apr 27, 2020 5:02 pm

Pugsy wrote: ↑
Mon Apr 27, 2020 4:56 pm
Auto CPAP mode is apap mode.

Two modes available on the Respironics model DSX500xxx Auto CPAP mode.

1...fixed cpap mode
2...auto cpap mode...which is apap mode or auto adjusting pressures.

where do I go from here?

milboltnut · Post by **milboltnut** » Mon Apr 27, 2020 5:21 pm

Pugsy wrote: ↑
Mon Apr 27, 2020 5:14 pm
You are in good hands with the help you have already received. I am not going to contradict anything they have told you. You've already gotten excellent advice.
You might go back an read again what the previous suggestions were.
Exactly what I told you a while back....you need more minimum pressure.

I am gonna increase .5 every few days.... of minimum pressure.. but what about the maximum pressure?

how does min/max pressure work? Does the min pressure compensate max pressure? or vice vera? what am I missing here?

Guess the bigger question is.. how does ramping up min pressure drop AHI?

Miss Emerita · Post by **Miss Emerita** » Mon Apr 27, 2020 5:54 pm

milboltnut wrote: ↑
Mon Apr 27, 2020 5:21 pm

I am gonna increase .5 every few days.... of minimum pressure.. but what about the maximum pressure?

Leave the maximum alone. Let it stay at 20. The pressure won't rise any higher than it needs to anyhow. For now, all that matters is the minimum. Your plan of going up .5 every few days is a good one.

how does min/max pressure work? Does the min pressure compensate max pressure? or vice vera? what am I missing here?

They are like barriers. The minimum tells the machine not to go any lower than that, and the maximum tells the machine not to go any higher. Sometimes there are some complicated reasons for changing the one when the other gets changed, but there's nothing like that here. You just need to try a higher minimum.

Guess the bigger question is.. how does ramping up min pressure drop AHI?

It's a good question, and a basic one. The more pressure you are getting, the more the machine is doing to keep your airway open. You always want to have pretty close to the amount of pressure you'll need when obstruction happens in your airway. If you put the minimum too low, you'll have one event, the machine will put the pressure up some, you'll have another, it'll go up some more, and so on. Meanwhile you are racking up events, which you don't want to do. Plus the minute your airway starts behaving, the pressure will drop back down to your minimum, starting the whole process over.

At the same time, you don't want more minimum than you need to treat your apnea. Higher pressures can be uncomfortable in various ways. No need to try coping with that if you don't have to.

So by going up .5 at a time, you'll be looking for the sweet spot: good treatment for your apnea, and minimal discomfort.

milboltnut · Post by **milboltnut** » Mon Apr 27, 2020 6:00 pm

ok.. so the higher minimum pressure prevents the machine from having to ramp up to deal with events.

If you put the minimum too low, you'll have one event, the machine will put the pressure up some, you'll have another, it'll go up some more, and so on. Meanwhile you are....... racking up events

The more (minimum) pressure you are getting, the more the machine is doing to keep your airway open.

that's how the minimum/maximum pressure work together.

Julie · Post by **Julie** » Mon Apr 27, 2020 7:01 pm

Actually - the higher min. does not keep the machine from having to rise... it just keeps events from occurring. If it was prevented from rising (ramping up) it couldn't do its job.

palerider · Post by **palerider** » Tue Apr 28, 2020 6:50 am

DreamDiver wrote: ↑
Mon Apr 27, 2020 2:17 pm
Looks like you're figuring it out. Way to go! Yeah, EPR and Flex are equivalent.

No, they're really not equivalent, EPR is a simple pressure drop 1cm per number, so up to 3cm pressure, and the pressure stays down until you start to inhale again.

*Flex varies with the force of respiration, up to about half of what EPR gives, and the pressure increases *before* inhalation, which fools many people into thinking the machine is trying to rush their breathing (it's not).

They may be, broadly speaking, something of the same concept, but they're implemented very differently.

Add to that, telling a non-Resmed user to do something with "EPR" is very confusing to them, since there is absolutely no mention of EPR *ANYWHERE* in any Respironics document.
[/quote]

palerider · Post by **palerider** » Tue Apr 28, 2020 6:57 am

DreamDiver wrote: ↑
Mon Apr 27, 2020 2:57 pm

milboltnut wrote: ↑
Mon Apr 27, 2020 2:26 pm
I can jack up the max too... 9 is what it usually is but the max on the machine is 20cm.??
So the 95 percentile pressure is 9cm.
That means most of the time, your pressure was a little under 9cm.

NO, that's not what it means *at all*.
https://adventures-in-hosehead-land.blo ... de-to.html
It means that for the entire night, pressure was at, or below 9cm.

It could have been at anything below the night for 94% of the time, and only been at 9 for a few minutes,
95% number is nothing but a statistic, like max pressure with any brief spikes dis-regarded, like how the olympics would throw out the top judges score (and bottom) and only count the middle ones.

DreamDiver wrote: ↑
Mon Apr 27, 2020 2:57 pm
If my median were 6cm and my 95% were 9cm, I would think about trying maybe 7 cm or 8cm minimum pressure.

You really shouldn't many *any* adjustments based on any of the statistical numbers, you should make adjustments based on what the pressure curves look like.

palerider · Post by **palerider** » Tue Apr 28, 2020 7:00 am

milboltnut wrote: ↑
Mon Apr 27, 2020 6:00 pm
ok.. so the higher minimum pressure prevents the machine from having to ramp up to deal with events.

If you put the minimum too low, you'll have one event, the machine will put the pressure up some, you'll have another, it'll go up some more, and so on. Meanwhile you are....... racking up events

The more (minimum) pressure you are getting, the more the machine is doing to keep your airway open.
that's how the minimum/maximum pressure work together.

Maximum pressure *setting* is normally irrelevant and should be left at the maximum possible, (20, or 25 depending on the machine).

The Minimum pressure is critical, and needs to be set high enough that it prevents *most* breathing events outright, then you let the auto function take care of exceptions (rolling onto your back, REM sleep, etc.)

DreamDiver · Post by **DreamDiver** » Tue Apr 28, 2020 8:40 am

palerider wrote: ↑
Tue Apr 28, 2020 6:50 am

DreamDiver wrote: ↑
Mon Apr 27, 2020 2:17 pm
Looks like you're figuring it out. Way to go! Yeah, EPR and Flex are equivalent.
No, they're really not equivalent, EPR is a simple pressure drop 1cm per number, so up to 3cm pressure, and the pressure stays down until you start to inhale again.

*Flex varies with the force of respiration, up to about half of what EPR gives, and the pressure increases *before* inhalation, which fools many people into thinking the machine is trying to rush their breathing (it's not).

They may be, broadly speaking, something of the same concept, but they're implemented very differently.

Add to that, telling a non-Resmed user to do something with "EPR" is very confusing to them, since there is absolutely no mention of EPR *ANYWHERE* in any Respironics document.

Thanks palerider! I was imprecise in my first sentence, but I did clarify later. Apologies for the confusion.
Just to make sure others understand, both methods provide a measure of exhale pressure relief, though they achieve it using different methods. The method used by PR "flex" algorithms make some people feel like the machine is trying to rush their breathing. Pugsy kindly posted a chart showing that the Flex algorithms provide up to 2cm of relief depending on various inputs.

You say Flex is not trying to rush breathing. If you're asleep while it's happening, and your subconscious interprets the pressure increase before inhalation as a cue to breathe faster, it seems that the point of whether the machine is or isn't "trying" to rush breathing is moot. The effect is evident regardless of what the machine is trying to do, eh? For some like me, flex algorithms make you feel like you're running a marathon all night. I used to wake up feeling like I'd been doing crunches all night. Unfortunately it did nothing for my abs.

I ended up hating the machine because you couldn't get exhale relief without an obnoxious Flex algorithm. Unfortunately, I'm not a fan of PR for so many reasons.

What would be interesting is getting a machine that would combine the best of both worlds. When someone is about to have a flaggable pressure-worthy event, use the PR flex style algorithm to entice the autonomic system to breathe a little better, but then when things get more stable, smoothly switch back to standard ResMed EPR algorithm. Pressure-worthy events that occur after that small change would raise the pressure as usual. Now it starts to sound a little like some of the more expensive machines...

Chris

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APAP adjustments

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