Leak Type Definition?

Can someone please look at the attached chart and tell me what kind of leak is represented in the tight, constant leak that is shown?

I'm using the OptiLife mask with pillows and Dr. Sue's dental device to prevent mouth breathing. The Auto is set at 7-10 cm.

I have very little movement once I settle in bed, so I'm, not rolling around.

I feel that the pillow is well sealed ... yet I have this constant leak activity ... which appears to drive the apneas.

Thanks.

Jan

Your leaks are fine. A "zipper-like" leak pattern is just as good the ideal straight line.

Your machine topped out at your max APAP setting of 10.

Unless you are sensitive to central apneas, you need to raise that max setting.

It looks like you are using ramp. With a starting pressure of 7 in a pressure range, ramp is not usually needed.

I see that your 90% is 10 cm and, according to "Daily Events per Hour", you are spending more than 1/2 of your night (55.3%) at a pressure of 10 and that's where, by far, the most apneas are happening. Once you hit 10 cm, with your settings, there no place to go and there are tons of apneas because you need more than 10 cm. You can see how the pressure line bumps up against 10 cm and stays there when it needs to go higher. It can't go higher because that's the limit you have set.

If it were me, I think I would set the minimum 10 (use ramp, if you think that is too high (at maybe 7 or and set the maximum at 20 cm to see just what is going on.

It doesn't look like you have any large leaks so, in my opinion, it's your pressure setting that is the problem.

What was your titrated pressure?

I agree with DreamStalker and Hawthorne. Leak looks fine. The maximum pressure setting doesn't look fine at all, at 10. That's an awful lot of obstructive apneas still hitting you, and the machine is not being allowed to raise the pressure more to try to prevent them.

If it were me, I'd try a night with the max set at 20, as Hawthorne suggested. I'd give the max plenty of ceiling room -- just to see what "real" max gets used.

rested gal wrote:I agree with DreamStalker and Hawthorne. Leak looks fine. The maximum pressure setting doesn't look fine at all, at 10. That's an awful lot of obstructive apneas still hitting you, and the machine is not being allowed to raise the pressure more to try to prevent them.

If it were me, I'd try a night with the max set at 20, as Hawthorne suggested. I'd give the max plenty of ceiling room -- just to see what "real" max gets used.

Thanks all for your comments.

So far, there seems to be a consensus ... to raise the upper limit.

Yes ... by the way, my doctor has expressed a concern over higher pressures and triggering my centrals. But he's not yet tried to push the limit.

He has a RT at his office ... but trying to communicate directly with her is an exercise in futility.

While my husband went on CPAP a week ago with Pacific Pulmonary as his DME. Their support group in in Central California ... yet he's been able to talk/work with the RTs three times in that week ... including a review of his EP reports!

Actually, Hawthorne and rested gal ... what you're suggesting is an "in-house" titration ...right?

Jan

Yes. That amounts to an "in home" titration to, at least, determine a more accurate therapy pressure for you.

You will need to watch for NRs (centrals).

Rested Gal, you didn't mention it specifically, but did you agree with me in suggesting that Jan set her minimum at 10 cm while raising the maximum to 20 cm?

I would go with a less agressive setting of 8 cm to 13 cm, less chance of triggering centrals. If you aren't use to driving a racetrack, why run open throttle. Jim

I agree with Jim. Since you are sensitive to centrals, setting max way up at 20 will be a disaster.

A min setting of 9 or 10 with a max of 12 or 13 would be a good start ... then inch up the max until AHI starts getting worse .. then back off again til you get the lowest AHI.

DreamStalker wrote:I agree with Jim. Since you are sensitive to centrals, setting max way up at 20 will be a disaster.

A min setting of 9 or 10 with a max of 12 or 13 would be a good start ... then inch up the max until AHI starts getting worse .. then back off again til you get the lowest AHI.

Jan may, or may not, be "sensitive to centrals." I don't think a few centrals turning up in her sleep study are an indication of a problem with centrals...yet.

Mar. 16, 2009 Interpertion & Accuarcy of the Respironics Display Data - topic started by janp:
viewtopic.php?p=349799#p349799
"My sleep study showed an AHI of 14/hr with a Central AHI of 5."

I don't think trying 20 as the maximum would produce any worse "disaster" than what's already showing up on her data with the max currently set at 10:


Sure, she could fiddle around with max 11, then 12, then 13, then 14, and so on, to see when she stops bumping the max. Or, she could set it for one night at 7 - 20 or 8 - 20 just to see what the data looks like. Just to see how much the machine does go to with her. If it soars up into the stratosphere (and her leak line continues to be as ok for the pressure being used as it is now) that could be useful information, imho.

Useful in this way: it's most unlikely that Jan really would need extremely high pressures since her sleep study resulted in a very low prescribed pressure ( 6 cm ) in the first place:

Mar. 16, 2009 Interpertion & Accuarcy of the Respironics Display Data - topic started by janp:
viewtopic.php?p=349799#p349799

"I'm currently using the REMstar Auto|APAP for diagnostics (I've been on the M Plus for 3 months). My husband had asked the doctor's office why I appeared to be having so many APNEA issues while asleep after being prescribed the REMstar Plus set at 6."

One night using a range of 7 - 20, or 10 - 20 might be rather revealing.

So might a few nights of single CPAP pressures, like 8 through 13, each tried for a couple of nights, as Den suggested back in this previous thread:
May 2, 2009 Encore Pro Report ... What is Happening??? - topic started by janp:
viewtopic.php?p=365683#p365683

janp wrote:

Wulfman wrote:The advantage of using CPAP mode (single pressure) is that it eliminates a number of variables.


Den

Den,

Thanks.

Looks like I'm headed back there.

Jan

Jan, did you ever get a chance to try some single CPAP pressures with your APAP?

If neither APAP nor CPAP are able to get Jan's "apneas" under control, she might want to talk to the doctor about the possibility of CompSAS (complex sleep apnea syndrome) in which application of CPAP (or autopap) actually brings on centrals.

Might also want to think about untreated or undertreated GERD (acid reflux) interfering with CPAP treatment. If the esophagus and upper airway are receiving nightly acid baths, the tissue could be becoming inflamed. Inflamed, irritated tissue can be swollen and rigid. CPAP air is designed to push aside soft tissue. Can't do much hitting a brick wall.

Thank you all for your input ... your opinions are much appreciated!

rested gal ... I'm amazed at the amount of research you do on previous posts ... WOW! And thanks!

By the way, the single pressure suggested by Den didn't work out ... at least for me.

I think I will try one night of "titration" with a higher pressure to see where the upper limit sorts out. I could go up one cm at a time, but that will take a while before I ... hopefully ... find the right setting.

The downside of the high setting is the potenental to trigger centrals. My doctor was concerned with my use of higher pressures for that reason.

They did have me do a study of 6 to 12 cm on a loaner machine a while back ... but the DME didn't share the data with me. I recall that the AHI was 17 something, but I don't know what the leakage was like and I know I was having a problem with mask leakage.

I'm thinking of trying one night at 8 to 15, keeping an eye on the NR index.

Again, thank you all ... it's really great of you all to take the time to respond.

Jan

janp wrote:Thank you all for your input ... your opinions are much appreciated!

By the way, the single pressure suggested by Den didn't work out ... at least for me.

Jan

Jan, Just curious about that comment. What single pressures did you try and for how long? What results did you get?

I'm curious too about the single pressure(s) tried.

Concise info from ResMed about Complex Sleep Apnea

http://www.vpapadaptsv.com/PDF/Complex- ... -Sheet.pdf

I wouldn't trust Respironics' identification of NR apneas to indicate if my apneas were central or not, it's much too rough for that.

O.

DoriC and ozij ... the CPAP settings that I reacall were 6, 9 and 12. I found (for me at least) that the 12 cm setting on CPAP with C-Flex was uncomfortable. I had too much difficulty exhaling. The A-Flex setting (vs the C-Flex) made it much easier for me the exhale at the higher pressure. That might be in part because I'm a shallow breather. I might toss in another variable - we're at 4100 feet elevation, so the air is thinner. My titration study was done at 500 feet elevation.

It would seem to me that I did better last night. There was one NR reported at about 12 cm ... but I'll try a second night at the same setting, before bumping the upper limit up to 17.

The attached EP chart is from last night:



The O2 stats looked pretty good also.

The attached SPO 7500 report is from last night:



All observations/comments are welcome.

Thanks.

Jan

I'm certainly not qualified but I'll be interested in hearing ozij's analysis of your chart. Thanks for posting it so we can all learn. Dori

Jan,
The SPO7500 software has additional info that may be very illuminating.
Right click on the study report - launch Vitascore.
Go to View in the Vitascore menu, click on View, Tools, and choose Study explorer.
Choose events on the window that opens to on the left side
You'll have a detailed list of each desats: when each happened, and it's length. Compare that info to your Encore Pro report.

Based on the Encore Pro alone, I would keep the machine on fixed pressure, at 8.

My reasons: you spend almost 3 hours there, and had a very quiet time. Once the pressure started rising - in response to an apnea or a hypopnea, it basically never stopped, except for the one time it ran into a non-responsives (6 of them) (at 3 hours). Respironics' technique if identifying 'NR' apneas is very rough - you have to have something like 6 apneas appearing within a few minutes for the machine to say "uh oh, I goofed" but it can goof when central apneas are not that close together -- and it won't realize that.

Now - you could of course have turned on your back after about 2.5 hours, or started belated dreaming - both can theoretically explain the rising pressure -- but -except for that small post NR pause - it's rising and rising and rising.... it looks like a vicious cycle to me.

The Respironics Auto should able to adjust its pressure to the altitude - but I wonder of the altitude doesn't change your breathing pattern in a way that confuses the machine.

If it were me, I would try a week or 2 at fixed 8 -or auto at 7-9 and track the saturation to see what's happening.
I'm not a professional, just a CPAP user - and I may be wrong.

O.